TANDARD 


MEDICAL 


FEBRUARY 


LON  THE 

-Cf-LEC-E  OF  OrSTEOFATf-ffC 
^fCf/:fi 

PATHOLOGY  AND  TREATMENT 


OP 


GONORRHCEA! 


BY 


Jd^L.    MILTON, 

SENIOR  SURGEON  TO  ST.  JOHN'S  HOSPITAL,  FOR  DISEASES  OF  THE  SKIN,  LONDON 


FIFTH  EDITION 


NEW  YORK 
WILLIAM    WOOD    &    COMPANY 

56  &  58  LAFAYETTE  PIACE 
»      1884 


nO  MJ 

OltriWWC   - 

,n^  '      ^ 


TROWS 

miNTIHG  AND  BOOKBINOmO  COUPANT, 
HEW  YOflK. 


PREFACE. 


THE  following  work  contains,  in  an  abridged  form,  the  substance 
of  the  earlier  editions ;  the  papers  on  scalding,  chordee,  and  gonor- 
rhoea printed  in  the  Medical  Times  /  those  on  the  treatment  of  gon- 
orrhoea published  in  the  Medical  Circular,  and  several  papers  read 
before  the  Medical  Society  of  London  and  the  Korth  London  and 
Western  Medical  Societies.' 

The  sections  on  the  treatment  of  gleet,  on  gonorrhoea  in  the  female, 
on  orchitis,  and  on  gonorrhoeal  rheumatism,  have  been  revised  and 
amplified.  Those  on  gonorrhceal  affections  of  the  heart  and  peri- 
cardium, the  peritoneum  and  pleura,  dura  mater  and  sheath  of  the 
spinal  cord ;  on  gonorrhceal  pyaemia,  pyelitis,  etc.,  are  now  added  for 
the  first  time. 

With  the  view  of  reducing  the  bulk  of  the  work,  many  of  the 
cases  given  in  the  first  edition  have  been  omitted,  and  those  which  are 
retained  have  been  selected  chiefly  as  examples  absolutely  necessary  to 
show  the  power  of  certain  remedies,  or  because  they  illustrate  peculiar 
forms  of  the  disorder  which  have  been  rather  overlooked.  It  was  in- 
dispensable to  retain  these  in  a  work  intended,  not  for  a  class  book, 
but  as  one  of  reference  for  the  busy  practitioner.  The  same  reasons 
which  induced  me  to  leave  out  superfluous  cases,  make  it  incumbent 
to  dispense  with  all  description  of  symptoms. 

It  is  not  to  be  expected  that  the  adverse  judgment  passed  upon 
many  remedies,  which  have  been  at  one  time  or  other  so  strongly  ad- 
vocated, will  prove  acceptable  to  those  who  recommended  them  to 
public  favor.  But  for  this  there  is  no  help.  Experience  compels  me 


IV  PREFACE. 

to  say  that  they  have  not  fulfilled  the  expectations  which  the  first 
accounts  of  them  were  calculated  to  raise. 

Whether  the  attempt  now  made  to  prove  that  gonorrhoea  may, 
when  admitting  of  removal,  be  cured  without  the  use  of  the  so-called 
specifics,  is  hased  on  sufficient  grounds  or  not,  it  would  ill  become  me 
to  say.  This  much,  however,  I  can  vouch  for ;  the  doctrines  I  have 
ventured  to  lay  down  have  been  pretty  severely  tested.  Nothing  ha& 
been  recommended  by  myself  in  this  work  but  what  has  stood  the 
brunt,  not  merely  of  experience,  for  that  I  rate  rather  low,  but  of 
special  observation.  My  aim  was,  as  far  as  possible,  to  separate  clearly 
what  might  be  looked  on  as  established  from  what  was  doubtful,  and 
not  merely  to  prove  every  assertion,  but  to  place  it  on  such  a  basis  that 
it  could  not  be  disproved.  How  far  I  have  succeeded  I  leave  to  the 
decision  of  my  readers.  For  the  remedies  advised,  or  the  views  up- 
held, by  other  authors,  I  do  not  hold  myself  answerable.  I  considered 
my  task  was  to  select  what  seemed  most  likely  to  improve  treatment, 
and  only  hope  I  have  executed  it  in  a  satisfactory  way. 

That  such  a  work  was  needed  is  proved  by  its  steadily  increasing 
sale  among  the  profession ;  that  the  mode  of  examining  the  thera- 
peutic action  of  remedies,  adopted  in  it  from  the  very  first,  was  sound, 
is  shown  by  so  many  authors  having  testified  to  the  accuracy  of  the 
results  obtained,  as  also  by  the  British  Medical  Association  having 
appointed  a  committee  to  carry  out  the  same  method,  but,  with  all 
deference  be  it  said,  in  a  much  less  exact  and  complete  shape. 

18  SUFFOLK  STREET,  PALL  MALL, 

LONDON,  S.  W.,  and 
SIGN  HOUSE,  KING'S  ROAD,  S.W., 
Nmember,  1883. 


CONTENTS. 


CHAPTER  L 

HISTORY  OF  GONORRHOEA,  p.  1. 


CHAPTER  H. 

PATHOLOGY  or  GONORRHCSA. 

GENESIS  OF  GONORRHCEA — A,  IN-  THE  MALE,  12  ;  B,  IN  THE  FEMALE,  26  ;  Point 
at  which  Infection  takes  place  in  the  Male,  Seat  of  Gonorrhoea  in  the 
Male,  32  ;  Period  of  Incubation,  37  ;  Seat  of  Gonorrhoea  in  the 
Female,  38  ;  Period  of  Incubation,  Milder  Nature  of  Gonorrhoea  in 
subsequent  Attacks,  39  ;  Does  Gonorrhoea  infect  the  System  ?  40  ; 
Prognosis  of  Gonorrhoea,  Results  of  Gonorrhoea,  40  ;  Origin  of  Gonor- 
rhoea from  a  Fungus,  45  ;  Micrococcus  peculiar  to  Gonorrhoea,  46  ; 
Varying  Duration  of  Gonorrhoea — Connection  between  Inveteracy 
and  Diathesis,  49. 


CHAPTER  HL 

TREATMENT  OF  GONORRHCEA. 

VARIETY  OF  REMEDIES  RECOMMENDED,  54  ;  Continuance  of  the  same  funda- 
mental Principles  of  Treatment,  55  ;  Sydenham's  Treatment,  58  ; 
Moyle's,  59  ;  Marten's,  60  ;  Turner's,  61 ;  Cockburn's  and  Astruc's,  62  ; 
Hunter's,  Howard's  and  Foot's,  64  ;  Sir  Astley  Cooper's  and  Judd's,  65  ; 
Expectant  Treatment,  68  ;  Gonorrhoea  as.  a  Cause  of  Stricture,  70  ; 
Table  I. — Cases  of  Gonorrhoea  Treated  in  different  Ways,  71. 


VI  CONTENTS. 

CHAPTEK  IV. 

TREATMENT  OF  GONORRHCEA  (continued). 

CLASSIFICATION  OF  KEMEDIES.  A.  INTERNAL  REMEDIES  : — 1.  Copaiba,  73 ;  Table 
IL — Cases  treated  with  Copaiba,  75  ;  Dose  and  Mode  of  giving 
Copaiba,  77  ;  2.  Cubebs,  80  ;  3.  Kava-kava,  81  ;  4.  Turpentine,  82  ; 
5.  Ngan-Plang,  83 ;  6.  Matico,  83  ;  7.  Oil  of  Sandal-wood,  84  ;  8. 
Gurgun  or  Gurghun,  87  ;  9.  Erigeron  Oil,  87  ;  10.  Antiphlogistic 
Means,  88  ;  11.  Purgatives,  89  ;  Table  IH.— Cases  Treated  with  Pur- 
gatives, 90  ;  12.  Aperients,  91 ;  Table  IV. — Cases  Treated  with  Aperi- 
ents, 91 ;  13.  Diuretics,  94 ;  14  Alteratives,  94  ;  B.  EXTERNAL  APPLI- 
CATIONS : — 1.  Cold  Applications,  95  ;  2.  Hot  Applications,  96  ;  Form 
for  calculating  Action  of  Remedies,  96  ;  3.  Sedative  Applications,  98  ; 
C.  DIRECT  APPLICATIONS  : — 1.  Injections,  Variety  of  Substances  used, 
100  ;  Can  Injections  bring  on  Stricture  and  Orchitis  ?  105  ;  Nitrate  of 
Silver,  110  ;  Table  V. — Cases  Treated  with  strong  Injections  of  Nitrate 
of  Silver,  111  ;  Chloride  of  Zinc,  113  ;  Table  VI.— Cases  Treated  with 
Injections  of  Chloride  of  Zinc,  115  ;  Table  VIE. — Cases  Treated  by 
Ricord,  117  ;  Table  VllL — Cases  Treated  by  Judd,  Duration  of  Treat- 
ment under  various  Injections,  Nitrate  of  Silver  Pastilles  (soluble 
Bougies),  118 ;  Glycero-Tannin  Rods,  120  ;  Conclusions,  121 ;  Pro- 
posed Plan  of  Treatment — A.  IN  THE  MALE,  Abortive  Treatment,  122  ; 
Ordinary  Treatment,  124  ;  Injections,  126  ;  Syringes,  128  ;  Mode  of 
Injecting,  129  ;  The  long  Urethral  Syringe,  132  ;  The  Caustic  Plug, 
134  ;  Cauterizing  the  Urethra,  136 ;  Blistering  the  Penis,  137  ;  Search 
for  Complications,  140 ;  B.  IN  THE  FEMALE,  142  ;  Injections,  143  ; 
Chronic  Inflammation  of  Canal  of  Cervix,  Uterine  Discharges,  145  ; 
Ovaritis,  146  ;  Affection  of  Duverney's  Glands,  148  ;  Abscess  of  Labia 
Majora,  Inflammation  of  erectile  Tissue  of  Vagina,  Excessive  Men- 
struation, Pain  in  Back,  etc.,  149 ;  Diet,  150  ;  Smoking,  151. 


CHAPTER  V. 

TREATMENT  OF  GONORRHCEA  (continued). 

COMPLICATIONS  WHICH  DO  NOT  INTERFERE  WITH  THE  CUBE  OF  GONORRHCEA. — 1. 
SCALDING  : — Pathology,  153  ;  Treatment,  Remedies  usually  recom- 
mended, 1.  Anodynes,  156 ;  2.  Demulcents,  157  ;  3.  Diuretics,  157  ; 
4.  Alkalies,  158  ;  Probable  Explanation,  Proposed  Plan  of  Treatment, 
161 ;  2.  CHORDEE  : — Pathology.  162  ;  Prognosis,  Results,  165  ;  Treat- 
ment usually  adopted,  186  ;  Proposed  Plan  of  Treatment,  167 ;  3. 
SYMPATHETIC  BUBO,  169  ;  4.  IRRITABLE  BLADDER,  169  ;  5.  ORCHITIS  : — 


CONTENTS.  Vll 

Pathology,  179  ;  Causes,  173  ;  Table  IX.— Statistics  of  Orckitis,  171 ; 
Prognosis,  Results,  187  ;  Treatment  usually  adopted,  189  ;  Puncture 
of  the  Tunica  Albuginea,  191  ;  Puncture  of  the  Tunica  Vaginalis,  194  ; 
Strapping  the  Testicle,  1 95  ;  Mr.  Gay's  Treatment,  196  ;  M.  Bonna- 
font's,  M.  Langlebert's,  197 ;  Proposed  Plan  of  Treatment,  198 ; 
Blistering  the  Scrotum,  200  ;  Subsequent  Treatment,  201 ;  Deferenti- 
tis,  202  ;  Inflammation  of  Spermatic  Cord,  202  ;  6-7.  PHIMOSIS  AND 
PABAPHIMOSIS,  203  ;  8.  BALANITIS,  204 ;  9.  INFLAMMATORY  SWELLING  OF 
THE  PENIS,  205 ;  10.  INFLAMMATION  OF  THE  SPONGY  AND  CAVERNOUS 
BODIES,  206. 


CHAPTER  VI. 

TREATMENT  OF  GONORRHCEA  (continued). 

COMPLICATIONS  WHICH  INTERFERE  WITH  THE  CURE  OF  GONORRHCEA  : — 1.  FAINT- 
ING FROM  THE  USE  OF  INJECTIONS,  Cases,  207 ;  2.  GREAT  NATURAL  OR 
INDUCED  WEAKNESS,  209  ;  Cases,  209  ;  3.  TENDENCY  TO  INFLAMMATION 

OF    THE   LACUNA   OF   THE   URETHRA,    212  J     4.    MORBID    SENSIBILITY   OF    THE 

URETHRA,  215 ;  5.  STRONG  TENDENCY  TO  STRICTURE,  216 ;  Caustic- 
holders,  218  ;  The  Cage  Bougie,  220  ;  6.  RETENTION  OF  URINE,  221 ; 
Treatment,  221 ;  7.  BALANITIS  OCCURRING  ALONG  WITH  PHIMOSIS  AND 
STRICTURE,  222  ;  8.  EXCESSIVE  IRRITABILITY  OF  THE  BLADDER,  222  ;  9. 
INFLAMMATION  OF  THE  BLADDER,  224 ;  10.  EXCESSIVE  IRRITABILITY  OF 
THE  RECTUM,  224  ;  11.  PERINEAL  ABSCESS,  224 ;  Cases,  225  ;  12.  IN- 
FLAMMATION OF  THE  PROSTATE — Pathology,  Divisions  : — 1.  Acute  ;  2. 
Subacute  or  Chronic  (Congestion  of  the  Prostate),  226 ;  Prognosis, 
Results,  227  ;  Treatment,  227 ;  13.  INFLAMMATION  OF  THE  SEMINAL 
VESICLES,  228  ;  14.  GONORRHCEAL  PERITONITIS,  229 ;  Prognosis,  230 ; 

15.  SUB-PERITONEAL  INFLAMMATION,   230  ;    Prognosis,   Treatment,  230 ; 

16.  GONORRHCEAL   PERINEPHRITIC   ABSCESS,  232 ;    17.    GONORRHCEAL    (?) 
PYEUTIS  AND  NEPHRITIS,   Cases,   233 ;    18.  GONORRHCEAL  (?)   PLEURITIS, 
234  ;    19.  GONORRHCEAL  RHEUMATISM,  History,   234  ;    Pathology,  235  ; 
Divisions,  240 ;    Gonorrhoeal  Synovitis,   242  ;    Gonorrhoea!  Sciatica, 
244  ;  Gonorrhceal  Rheumatism  in  Women,  246  ;  Complications,  a-b, 
Gonorrhceal  Endocarditis  and  Pericarditis,  247 ;  c.  Gonorrhceal  Menin- 
gitis, 251  ;  d.  Gonorrhceal  Myelitis,  252  ;  e.  Gonorrhceal  (?)  Hepatitis, 
252  ;  /.  Gonorrhceal  (?)  Nephritis,  253  ;  g.  Gonorrhceal  Pyaemia,  253  ; 
h.  Gonorrhceal  Adenitis,  etc.,  254  ;  Mode  in  which  Gonorrhoeal  Rheu- 
matism is  set  up,  Prognosis,  255  ;  Treatment  usually  adopted,  259  ; 
Proposed  Plan  of  Treatment,  258  ;  20.  GONORRHCEAL  AFFECTIONS  OF  THE 
EYE — a.   Ophthalmia,   Pathology,  262  ;  Prognosis,  Treatment  usually 
adopted,  263  ;  Proposed  Plan  of  Treatment,  265  ;  b.  Gonorrhceal  Iritis, 


Vlll  CONTENTS. 

Pathology,  Prognosis  ;  c.  Bheumatism  of  Eyeball,  Pathology,  266  ; 
Prognosis,  Treatment ;  d.  Aquo-capsulitis,  267  ;  21.  STRONG  TENDENCY 
TO  BLEEDING,  268. 


CHAPTEK  VIL 

PATHOLOGY  AND  TREATMENT  OF  GLEET. 

PATHOLOGY  : — 1.  GONORRHCEA  OF  LONG  STANDING,  269  ;  2.  INVETERATE  GON- 
ORRHCEA,  269  ;  3.  Muco -PURULENT  GLEET,  270  ;  4.  PROSTATIC  GLEET, 
270  ;  5.  PURE  Mucous  GLEET,  271 ;  Dr.  Otis's  Views,  271  ;  The  Endo- 
scope,  Auspitz's  Researches,  273  ;  Gleet  of  Cowper's  Ducts,  276  ; 
Treatment — A.  IN  THE  MALE,  277  ;  First  Class — Gonorrhoea  of  Long 
Standing,  280  ;  The  Bougie,  281  ;  Nitrate  of  Silver,  284  ;  Potassa  fusa, 
285 ;  Blistering,  286  ;  Diet  in  Gleet,  288  ;  Complications  of  Gleet, 
288  ;  Second  Class — Inveterate  Gonorrhoea,  289  ;  Third  Class — Muco- 
purulent  Gleet,  290  ;  Fourth  Class— Prostatic  Gleet,  290  ;  Fifth 
Class — Pure  Mucous  Gleet,  Gleet  of  Cowper's  Ducts,  292  ;  B.  IN  THE 
FEMALE,  293. 

x 

INDEX  . .  .   295 


ON    GONORRHOEA 


CHAPTEE  I. 

HISTORY. 

THAT  gonorrhoea  existed  from  a  very  early  period  is  probable  enough,  but 
much  of  what  has  been  written  respecting  the  question  is  unreliable  and 
conjectural  in  the  highest  degree.  Mr.  Berkeley  Hill,  quoting  from  Dabry, 
says  '  that  it  was  described  4,500  years  ago  in  the  collection  of  medical 
treatises  made  by  the  emperor  Ho-Ang-Ti.  I  have  not  been  able  to  obtain 
access  to  the  work  Mr.  Hill  quotes  from,  but  I  always  heard  that  he  was 
extremely  painstaking,  and  I  see  nothing  improbable  in  the  statement.  If, 
however,  the  Chinese  writer's  description  of  gonorrhoea  be  so  full  and  ac- 
curate that  we  can  unequivocally  recognize  the  disease,  it  is  not  merely 
the  earliest,  but  the  only  unimpeachable,  account  to  be  found  for  at  least 
thirty-six  centuries  after. 

M.  Chabalier  traces  the  descent  of  gonorrhoea  from  the  time  of  Moses 
downward,  in  a  memoir2  perhaps  never  yet  surpassed  for  elegance  and 
scholarship  ;  but  while  I  cheerfully  accord  to  it  all  praise  on  this  head,  I 
must  contend  that  his  desire  to  carry  his  point  sometimes  gets  the  upper 
hand  of  his  judgment.  The  cause  could  scarcely  have  been  taken  up  by  a 
more  able  advocate,  but  even  in  his  hands  it  is  one  of  the  weakest  ever  yet 
argued  for. 

He  begins  with  the  often-cited  passage  from  Leviticus,  about  a  person 
with  a  running  issue  out  of  his  flesh.  He  maintains  that  this  must  be 
gonorrhoea,  although  in  the  very  next  verse  we  are  told  that  such  a  person 
is  equally  unclean,  whether  his  flesh  run  with  or  be  stopped  from  his 
issue  ;  as  if  any  human  being  could  identify  a  complaint  described  in  such 
terms,  which  so  far  as  we  can  understand  them  at  all,  might  just  as  easily 
mean  an  ulcer  of  the  leg  with  or  without  proud  flesh  in  it.  The  fact  is 
that  men  speak  very  confidently  about  diseases,  e.g.,  syphilis,  lepra,  ele- 
phantiasis Gra?corum  and  furunculus,  being  portrayed  in  the  writings  of 

1  Syphilis  and  Local  Contagious  Diseases,  p.  6.    1868. 

2  These  pour  le  Doctorat  en  Medecine.     1860. 


2  ON    GONORRHOEA. 

Moses  ;  but  in  reality  any  description  found  there,  of  any  one  of  these 
diseases,  would  at  once  break  down  if  confronted  with  the  simplest  defini- 
tion of  the  complaint  ever  yet  given,  and  all  the  more  certainly  when  we 
recollect  how  doubtful  we  must  ever  feel  about  the  nature  of  much  of  the 
translation  from  the  Hebrew  writ. 

M.  Chabalier's  next  contention  is  that  Hippocrates  described  five  kinds 
of  leucorrhoea,  irrespective  of  those  arising  from  inflammation  of  the 
womb.  But  a  description  of  five  and  fifty  would  bring  us  no  nearer  the 
mark  unless  it  showed  that  one  of  these  was  a  purulent  inflammation  of 
the  vagina  and  urethra  derived  from  intercourse,  and  in  its  turn  conveying 
infection  to  the  male  ;  and  I  presume  M.  Chabalier  will  admit  that  this  is 
one  of  the  things  which  we  do  not  find  in  Hippocrates.  As  to  the  quota- 
tion from  Herodotus  next  brought  forward  by  M.  Chabalier,  about  the 
Scythians  being  afflicted  with  a  running  from  the  penis,  I  must,  for  rea- 
sons given  elsewhere,1  affirm  that  there  is  not  the  least  justification  for 
such  a  rendering  of  the  passage,  which  clearly  refers  to  a  visible  and  here- 
ditary complaint.  If  M.  Chabalier  will  bring  forward  the  name  of  any 
commentator  or  lexicographer,  who  has  thus  translated  in  print  the  Greek 
adjective  used  by  Herodotus,  I  will  at  once  admit  that  he  may  be  right ; 
till  then  I  must  contend  that  he  is  entirely  wrong.  The  meaning  of  the 
term  is  hidden  in  impenetrable  obscurity,  and  though  it  was  used  for  ages 
after,  only  the  vaguest  of  ideas  was  attached  to  it.  But  for  one  fatal  ob- 
jection I  should  feel  inclined  to  take  part  with  Astruc,  who,  quoting  from 
Hippocrates,  says  these  Scythians  were  simply  eunuchs  who  dressed  like 
•women  and  did  woman's  work.  The  objection  is  that  the  complaint  was 
considered  to  be  hereditary,  and  that  in  no .  age  or  country  did  eunuchs 
ever  do  anything  of  the  kind. 

After  Herodotus  comes  Celsus,  who  is  ushered  forth  as  describing 
gonorrhoea  and  orchitis.  No  better  authority  than  that  of  the  famous  old 
Roman  surgeon  need  be  asked  for,  if  we  only  felt  sure  that  we  are  dealing 
with  attested  facts.  But  the  truth  is  that  Celsus  never  does  anything  of 
the  kind.  He  describes  primary  sores,  balanitis  and  phimosis,  but  as  to 
gonorrhoea,  there  is,  in  the  whole  of  his  work,  not  merely  no  definition, 
but  not  one  unequivocal  symptom  of  it,  and  the  orchitis  he  mentions  was 
most  probably  hydrocele.  Certainly  it  was  not  gonorrhoea!,  for  he  speaks 
of  it  as  arising  without  inflammation,  a  very  unlikely  account  for  so  great 
an  observer  as  Celsus  to  give  of  an  affection  which  bears  all  the  visible 
marks  of  this  state.  Besides,  if  Celsus  had  been  at  all  acquainted  with 
gonorrhoea!  orchitis,  he  would  have  referred  it  to  its  proper  cause ;  the 
connection  between  the  inflammation  of  the  urethra  and  that  of  the  testicle 
is  so  direct  and  so  palpable,  that  I  question  whether  any  one  ever  yet  made 
a  mistake  as  to  what  gonorrhoea!  orchitis  was  due  to.  The  same  may  be 


1  A  History  of  Syphilis,  p.  2.    1879. 


HISTOEY.  3 

said  of  at  least  two  or  three  antecedent  symptoms.  Among  many  gonor- 
rhoea patients  some  will  be  sure  to  have  the  disease  in  a  severe  form,  and 
I  should  say  that  the  constant  recurrence  of  thick  discharge,  turgescence 
of  the  penis,  scalding  and  chordee,  could  not  fail  to  rivet  the  attention  of 
the  most  superficial  observers. 

In  every  community  yet  discovered,  where  the  inhabitants  were  found 
to  be  capable  of  distinguishing  the  right  hand  from  the  left  and  daylight 
from  darkness,  it  has  been  observed,  I  believe  without  a  single  instance  to 
the  contrary,  that  if  gonorrhoea  had  settled  among  them,  it  enjoyed  not 
merely  a  local  habitation  but  a  name  also.  For  this,  among  many  other 
reasons,  I  believe  that  gonorrhoea  was  totally  unknown  to  the  Romans. 
Even  supposing,  what  seems  to  me  incredible,  that  it  had  by  chance  es- 
caped the  observation  of  Celsus,  the  entire  absence  of  all  mention  of  it,  in 
the  works  of  Horace,  Juvenal,  and  Persius  is,  in  my  opinion,  sufficient  to 
establish  the  position  I  have  taken  up.  I  consider  it  as  certain  that,  had 
gonorrhoea  existed  at  all  in  Rome  at  their  time,  they  would  have  known  of 
the  fact ;  and  most  improbable  that,  had  they  been  acquainted  with  the 
disease,  they  would  have  failed  to  notice  it.  They  were  not  likely  to  be 
restrained  by  any  scruples  of  delicacy  from  touching  upon  such  a  ques- 
tion, for  no  set  of  men  ever  exercised  less  reticence  in  dealing  with  these 
topics  than  the  Roman  satirists  ;  Juvenal  in  particular  was  certainly  out- 
spoken enough,  and  might  be  said  to  write  professedly  about  such  mat- 
ters. 

For  much  the  same  reasons  too  I  must  entirely  reject  the  evidence  of 
Cicero,  whom  M.  Chabalier  arrays  in  his  cause  on  the  strength  of  a  passage 
to  the  effect,  that  those  who  are  incontinent  suffer  from  dysuria,  a  term 
which  seems  to  have  meant  indifferently  stricture  and  strangury.  But  the 
passage,  if  it  can  be  considered  to  prove  anything  at  all,  shows  that  Cicero 
was  totally  unacquainted  with  gonorrhoea.  Strangury  is  by  no  means  a 
constant  sequela  of  this  affection,  and  not  unfrequently  attacks  persons 
who  have  never  been  affected  at  all.  Even  in  the  incontinent,  gonorrhoea 
is  not  in  any  way  a  necessary  medium.  I  presume  M.  Chabalier  is  aware 
that  the  first  Napoleon  suffered  rather  severely  from  strangury  during  the 
Russian  camgaign,  and  was  at  all  times  incontinent  enough ;  yet  there  is 
no  evidence  that  he  ever  laid  the  foundation  for  the  strangury  by  catching 
a  gonorrhoea.  Lastly,  I  must  express  my  conviction  that  Cicero  was  not 
at  all  likely  to  have  been  so  familiar  with  a  disease,  unknown  to  Juvenal 
and  Celsus,  as  to  make  his  opinion  of  any  weight.  Indeed  I  ought  perhaps 
to  say  that  the  words  quoted  seem  to  me  as  destitute  of  anything  like  a 
definite  meaning,  or  a  basis  of  truthful  observation,  as  a  passage  in  Pliny 
or  Rhazes  generally  is. 

M.  Chabalier  next  quotes  the  very  doubtful  authority  of  John  Mesue,  a 
Syriac  or  Persian  writer,  whose  era,  to  begin  upon,  is  so  uncertain  that 
biographers  differ  as  to  the  date  of  his  death  by  six  or  seven  and  twenty 


4  ON    GONORRHOEA. 

years ; '  while  there  is  good  reason  to  believe  that  his  works  are  a  forgery, 
an  utter,  and  in  one  respect  a  clumsy,  imposture,  Rhazes,  who  lived  a 
century  later,  being  quoted.2  But  though  as  a  question  of  history  such 
evidence  is  worthless,  it  yet  goes  to  show  that,  at  the  time  of  the  imposture 
or  interpolation  being  perpetrated,  gonorrhoea  was  in  existence,  as  we  are 
told  that  the  patients  suffered,  among  other  symptoms,  from  itching  or 
tickling  at  the  orifice  of  the  urethra  and  painful  erections.  If,  therefore, 
we  could  fix  the  date  of  the  writing,  the  passage  quoted  from  would  con- 
stitute a  valuable  landmark,  but  I  cannot  see  in  the  least  how  this  is  to  be 
done. 

M.  Chabalier  then  proceeds  to  deal  with  the  testimony  of  Haly  Abbas, 
who  lived  in  980,  and  who  speaks  of  obstruction  of  the  meatus  produced  by 
a  sufficiently  large  quantity  of  viscous  humor  which  glues  it  together  ;  of 
the  urine  burning  and  of  micturition  being  difficult,  symptoms  which  al- 
most certainly  point  to  gonorrhoea  and  to  it  only.  But  indeed  the  time 
when  this  disease  was  to  appear  indisputably  on  the  scene  in  the  shape  of 
the  Syknesse  of  Brennynge,  and  to  be  a  source  of  shame  and  torment  to 
man  ;  when  the  first  absolutely  reliable  landmark  in  its  history,  the  recog- 
nition of  its  contagious  character  and  propagation  by  sexual  intercourse, 
was  established  and  acted  upon,  though  far  off,  still  drew  near.  After 
Haly  Abbas  comes  Rhazes,  the  Persian,  who  however  in  strict  order  of  time 
should  have  preceded  him,  having  died  in  932  at  the  age  of  eighty.  From 
him  M.  Chabalier  has  contrived  to  extract  the  information,  that  he  men- 
tions the  case  of  one  Machumet,  a  patient,  of  whom  he  predicted  that  he 
would  have  a  gonorrhoea  because  he  had  seen  a  few  drops  of  pus  precede 
the  urine.  The  result  is  creditable  to  M.  Chabalier's  industry ;  but  by 
what  strange  chance  an  author,  who  spent  the  first  forty  years  of  his  life 
in  the  study  of  music,  philology,  and  philosophy,  and  who  during  some 
part  of  the  remainder,  for  he  went  blind,  wrote  at  such  a  rate  that  he  left 
two  hundred  and  twenty-six  works  behind  him  ;  who  took  to  physic  in 
comparatively  old  age,  and  could  never  have  gained  his  knowledge  at  the 
source  best  worth  notice,  the  strict  and  patient  watching  of  disease  ;  who 
borrowed  what  was  good  in  his  writings  from  the  Greek  writers  and  heaped 
a  perfect  Pelion  upon  Ossa  of  verbiage  on  the  top  of  it,  ever  got  at  an 
original  idea  at  all,  is  more  than  I  can  make  out. 

After  this  the  disease  is  traced  through  a  long  succession  of  authors. 
Thus  Avicenna  describes  internal  ulcers  of  the  penis  with  itching  of  this 
organ,  due  to  the  effusion  of  acute  matter  into  it ;  Alsaharavius  says  we 
may  prognosticate  ulcers  of  the  penis  and  bladder  when  there  exists  a  dis- 
charge of  putrefied  pus.  But  that  Avicenna  ascribes  a  contagious  quality 
to  this  discharge,  I  should  have  to  pass  by  his  testimony,  while  that  given 

1  Dictionnaire  Historique,  tome  iii.,  p.  284.     Par  H.  F.  J.  Eloy.     1778. 
*  The  History  of  Physick,  Part  II.,  p.  38.     By  J.  Friend,  M.D.     1726. 


HISTOKY.  5 

"by  Alsaharavius  is  of  the  weakest  nature.  The  strictures  which  Albucasem 
recommends  should  be  treated  with  leaden  sounds  were  not  improbably  of 
gonorrhoeal  origin,  and  Constantiue  the  African,  who  flourished  toward 
the  end  of  the  eleventh  century,  may  mean  the  same  thing  when  he  recom- 
mends soothing  measures  for  the  contraction  produced  by  a  purulent  run- 
ning. Gariopontus  of  Salemurn  (eleventh  century)  describes  blennorrha- 
gic  cystitis,  but  the  evidence  is  anything  but  conclusive  ;  the  symptoms 
are  more  severe  than  those  ever  seen  in  neglected  gonorrhoea,  and  they  are 
not  traced  to  such  a  source.  Tortula,  a  century  later,  speaks  of  balanitis  ; 
evidence  which  I  think  we  may  reject  as  weak.  Kogerius  describes  a  dis- 
ease marked  by  heat,  pricking  pains,  and  burning,  with  redness  and  in- 
flammation of  the  penis  ;  almost  certainly  gonorrhoea.  This  author  seems 
also  to  have  been  acquainted  with  orchitis.  M.  Chabalier  says,  that  John 
of  Gaddesden  (beginning  of  fourteenth  century)  describes  blenorrhagia  and 
recommends  a  suspensory  bandage  for  orchitis,  the  latter  piece  of  evidence 
being,  I  suppose,  decisive.  John  of  Concorreggio,  he  says,  describes  or- 
chitis, and  John  Arcalanus  gonorrhoea!  cystitis  and  running,  recognized  by 
issue  of  blood  or  sanies,  or  both,  with  pricking  or  biting  pains.  Guy  de 
Chauliac  prescribes  injections  when  heat  and  foul  discharge  (foetiditas) 
show  themselves  on  account  of  connection  with  an  infected  woman ;  also 
fairly  decisive  evidence.  John  of  Arden  (toward  close  of  fourteenth  century) 
counsels  injections  against  internal  burning  and  excoriation  of  the  male 
yard.  Andrew  Boord,  1546,  and  whose  account  is  here  accordingly  rather 
a  chronological  mistake,  speaks  of  the  contagious  nature  of  the  complaint ; 
and  lastly  M.  Chabalier  cites  the  evidence  of  Bernard  Gordon,  which  he 
had  better  have  left  out,  the  testimony  being  of  anything  but  a  convincing 
nature  ;  the  utmost  we  can  extract  being  that  among  the  affections  of  the 
penis  he  ranks  pain,  swelling,  and  itching. 

Thus  far  M.  Chabalier.  There  are,  however,  authors  who  go  a  long  way 
beyond  him,  and  if  we  were  guided  by  what  they  say,  we  might  safely  con- 
clude that  the  genealogy  of  gonorrhoea  can  be  as  clearly  traced  through  a 
long  chain  of  written  evidence  as  the  house  of  Guelph  or  Este  could.  There 
is,  however,  really  no  warrant  for  any  such  conclusion.  True,  a  host  of 
writers  can  be  selected  from  the  works  of  Gruner,  Hensler,  Astruc,  and 
Luisinius,  who  speak  of  gonorrhoea,  and  those  who  consider  such  evidence 
as  decisive  can  easily  make  out  a  case  for  an  almost  unbroken  history  of 
the  disease  from  a  very  early  date  down  to  quite  a  recent  period.  But 
this  is  far  from  the  true  state  of  the  question.  Undoubtedly  these  writers 
treat  of  gonorrhoea,  but  under  that  name  they  not  only  comprehend,  but 
some  of  them  exclusively  describe,  seminal  emissions  and  their  results. 
What  we  now  term  spermatorrhoea  was  the  parent  disease,  of  which  gon- 
orrhoea was,  by  the  few  who  really  noticed  it,  considered  to  be  a  variety. 
From  the  time  of  Galen  and  Pliny  downward  we  find  occasionally  depict- 
ed a  form  of  seminal  flux  which  was  considered  infectious,  and  so  far  as 


6  ON    GONORRHXEA. 

such  evidence  can  be  supposed  to  be  worth  anything  at  all,  it  helps  to 
prove  the  antiquity  of  the  disease.  But  every  now  and  then  every  trace 
even  of  this,  and  indeed  of  every  symptom  of  gonorrhoea,  disappears,  and 
we  are  face  to  face  with  a  picture  in  which  we  find  only  some  form  of 
spermatorrhoea,  not  one  symptom  of  the  other,  not  a  tittle  of  evidence  that 
the  author  had  ever  seen  a  case  of  gonorrhoea,  or  had  appreciated  the 
nature  of  the  complaint. 

This  occasional  mysterious  silence  is  easy  to  trace  when  we  turn  to  the 
mediaeval  writers,  and  pursue  the  thread  of  history  up  to  the  epoch  of 
syphilis ;  and  I  think  M.  Chabalier  himself  would  be  rather  puzzled  to 
find  in  some  of  their  descriptions  anything  like  a  picture  of  gonorrhoea. 
For  instance  Constantine  of  Carthage  is  often  quoted  as  familiar  with  this 
affection,  and  the  following  is  the  account  given  by  the  African  physician. 
"  Owing,"  he  says,  "  to  deficient  power  of  that  retention  which  is  natural 
to  the  vessels  containing  the  semen,  this  passes  away  involuntarily,  without 
desire  for  connection  and  without  pleasure  ;  the  act  takes  place  without 
erection  or  orgasm  of  the  seminal  vessels."  Comment  upon  such  a  de- 
scription is  quite  superfluous,  for  it  cannot  be  held  to  apply  in  any  way  to 
urethritis.  Arnold  of  Villanuova  and  Hugh  Bencius  seem  to  have  stood 
in  exactly  the  same  position  as  Constantine,  that  is  to  say  they  were  ac- 
quainted with  spermatorrhoea ;  beyond  this  their  knowledge  did  not  go. 
There  is  ample  ground  to  think  that  this  was  the  case  with  the  great  ma- 
jority of  the  writers  mentioned  by  Hensler  as  speaking  of  gonorrhoea,  and 
certainly  those,  whose  words  he  does  quote,  describe  in  every  instance 
an  affection  identical  in  nature  with  that  described  by  Constantine.  I 
should  be  inclined  to  limit  the  number  of  those  we  can  suppose  to  have 
been  acquainted  with  blennorrhagia,  strictly  to  those  who  speak  of  the 
contagious  nature  of  gonorrhoea,  or  who,  like  the  writer  of  Mcsue's  works, 
give  us  such  symptoms  as  itching  of  the  meatus,  scalding,  and  painful 
erections ;  all  reference  whatever  to  writers  who  simply  use  the  word 
gonorrhoea,  without  such  evidence  being  extracted  from  their  works  as  will 
satisfy  us  that  under  that  term  they  understood  what  we  now  under- 
stand, being  rigorously  excluded. 

This  materially  shortens  the  task  in  hand,  for  the  others  are  easily  dealt 
with.  If  to  the  evidence  taken  from  the  reliable  authors  quoted  by  M. 
Chabaher,  we  add  that  possibly  Pliny  and  Galen  were  in  some  degree  ac- 
quainted with  gonorrhoea,  as  the  idea  that  the  semen,  in  certain  states  of 
deterioration,  acquires  a  poisonous  quality  may  be  traced  back  to  them  ; ' 
that  Avicenna  describes  a  form  of  gonorrhoea  of  that  day  marked  by  mor- 
dication,  painful  erection,  and  scalding  ; "  and  that  Valescus  of  Tarentum, 
one  of  the  first  authors  who  for  ages  wrote  only  from  experience,  knew 
gonorrhoea,  but  evidently  considered  it  a  form  of  emissions,  we  have,  con- 

1  Hensler's  Geschichte  der  Lustseuche,  S.  190.  s  Ibid.,  p.  178. 


HISTORY.  7 

centrated  in  the  few  foregoing  lines,  all  the  lore  of  gonorrhoea  scattered 
through  fourteen  centuries.  I  see  no  reason  to  think  that  we  can  track  its 
history  through  an  uninterrupted  descent  down  to  the  epoch  of  syphilis. 
On  the  contrary  the  account  of  it  constantly  breaks  off  as  abruptly  as  any 
old  fragment  of  a  nursery  tale  ;  the  disease  vanishes,  if  not  from  human  at 
least  from  medical  ken,  and  complete  obscurity  envelopes  the  scene  for 
long  periods  together.  Hensler  at  once  admits  this.  Too  honest  to  wrest 
evidence  to  his  purpose,  he  confesses  himself  unable  to  understand  how  it 
happens  that  the  outline  of  the  disease  is  at  one  time  expanded  to  its  nor- 
mal dimensions,  at  another  contracted  to  such  narrow  limits,  and  again  at 
another  lost  in  impenetrable  darkness.  Between  the  latter  part  of  the 
twelfth  century  and  the  era  of  syphilis  there  flourished  eight  men  who 
stand  prominently  forward  as  speaking  with  some  degree  of  authority  on 
these  subjects.  They  are  Michael  Scott,  William  of  Salicetus,  Lanfranc  of 
Milan,  Peter  d'Argelatta,  Valescus  of  Tarentum,  John  Ardern,  John  of 
Gaddesden,  and  Bernard  Gordon.  The  four  first  seem  to  have  been  totally 
ignorant  of  gonorrhoea ;  I  see  no  evidence  in  the  quotations  from  their 
writings  that  they  had  ever  suspected  its  existence.  The  fifth,  as  already 
mentioned,  describes  nothing  more  or  less  than  spermatorrhoea,  and  the 
evidence  of  Gordon  is  too  weak  to  be  relied  on. 

With  the  arrival  of  what  is  generally  known  as  the  first  invasion  of 
syphilis,  gonorrhoea  disappears  from  the  scene  with  a  suddenness  and  com- 
pleteness calculated  to  surprise  us,  when  we  consider  how  widely,  compar- 
atively speaking,  knowledge  was  now  diffused  by  means  of  printing. 
Benedetti  seems,  according  to  Hensler,  to  have  been  acquainted  with  the 
disease,  that  is  to  say  he  was  most  probably  acquainted  with  the  seminal 
discharge,  and  had  heard,  like  so  many  more,  of  the  name.  From  the 
same  author  we  learn  that  faint  traces  of  a  knowledge  of  gonorrhoea  are  to 
be  found  in  Marcellus,  Griinbeck,  Steber  ;  but  such  dun  and  scanty  mem- 
orials are  valueless  for  the  reason  already  urged,  that  unless  an  author's 
definition  is  given,  we  never  know  whether  we  are  dealing  with  the  gonor- 
rhoea of  modern  days  or  not.  Indeed  this  was  then  so  unknown  or  over- 
looked, that  Hensler  says  that,  during  what  he  calls  the  first  period  of 
syphilis,  the  epoch  of  its  imagined  malignity,  he  can  scarcely  find  a  trace 
of  the  name  and  none  of  the  disease  itself  ;  and  it  is  to  be  remembered 
that  the  name  embraced  every  discharge  from  the  urethra. 

With  the  arrival  of  the  second  period,  that  of  the  decline  in  syphilis 
from  its  first  intolerable  fury,  gonorrhoea  resumes  its  place  in  nosology, 
being  now,  1504  or  5,  described  by  James  Cataneus  in  a  work  which  Hen- 
sler and  Astruc  agree  in  praising  as  the  best  of  its  kind  that  had  ever 
yet  appeared  on  these  subjects.  Cataneus  indeed  was  greatty  in  advance 
of  all  previous  writers,  especially  as  regards  the  contagious  nature  of  the 
affection  ;  he  had  evidently  studied  Nature  quite  as  much  as  he  had  Galen 
and  Avicenna,  and  he  studied  her  better  than  they  did,  for  he  penetrated 


8  ON    GONORRHOEA* 

farther  into  her  secrets.  He  not  only  speaks  of  gonorrhoea  being  conta- 
gious, but  says  that  it  may  arise  without  the  infecting  person  having  an 
ulcer.  He  even  taught '  that  a  woman,  who  had  cohabited  with  an  affected 
man,  might,  while  herself  healthy,  convey  the  disease  ;  the  first  clear,  un- 
equivocal announcement,  I  believe,  of  its  contagious  qualities  before  the 
days  of  Paracelsus.  Benedetti  seems  to  have  been  familiar  with  the  name, 
but  I  have  not  been  able  to  make  out  whether  he  was  acquainted  with  the 
disease  itself. 

Another  turn  of  the  kaleidoscope  of  Time  and  the  disease  again  van- 
ishes. Hensler  finds  mention  of  it  in  the  Trias  Romana,  date  unknown, 
but  earlier  than  is  usually  supposed,  1542,  as  Ulrich  von  Hutten  was  ac- 
quainted with  the  book.  From  what  little  can  be  made  out,  it  is  not  im- 
probable that  blennorrhagia  is  really  alluded  to,  but  I  do  not  see  how  any- 
thing like  certainty  can  be  arrived  at,  the  passage  quoted  being  simply  to 
the  effect  that  there  were  then  "  three  citizens  at  Rome,  Simon,  Judas,  and 
the  gonorrhoea  people."  He  also  reports  mention  of  it  in  the  works  of  the 
elder  Beroaldus,  1515,  in  whose  account  however  I  see  nothing  beyond 
some  hazy  idea  about  what  was  probably  premature  emission,  of  which  he 
certainly  takes  a  most  lugubrious  view.2  With  these  exceptions  all  is  silence 
till  Bethencourt  described  it  in  1527,  and  Paracelsus  in  1527  or  28,  after 
which  it  once  more  vanishes  for  nearly  forty  years,  a  solitary  and  most 
doubtful  notice  of  it  by  Gattinara  or  Gatinaria,  1539,3  possibly  excepted. 
Hensler  quotes 4  several  authors  between  1532  and  1563,  including  Massa, 
whose  publications  range  over  the  whole  of  this  period,  and  Fracastori, 
whose  knowledge  was  supposed  to  embrace  the  literature  of  all  times, 
countries,  and  subjects,  not  one  of  whom  alludes  to  the  disease.  Some 
writers,  however,  consider  that  venereal  gonorrhoea  is  plainly  indicated  in 
the  works  of  Brassavolus,  1551,  Fernelius,  1555,  and  Fallopius  about  1560. 

Through  all  these  ages  of  time,  through  all  this  long  succession  of 
authors,  not  the  slightest  progress  had  been  made  toward  a  real  knowledge 
of  the  pathology  of  gonorrhoea.  Men  had  been  quite  content  to  copy  from 
one  another,  and  the  mediaeval  writers  could  not,  any  more  than  their  pre- 
decessors, get  beyond  the  idea  that  all  varieties  of  gonorrhoea  were  only  so 
many  forms  of  discharge  of  semen ;  the  disease  was  an  affection  of  the 
seminal  vessels,  not  of  the  urethra  at  all,  an  error  I  need  scarcely  say  still 
perpetuated  in  the  name  we  continue  to  give  to  the  disease.  In  this  re- 
spect the  pathology  of  Valescus  of  Tarentum  is  not  a  step  in  advance  of 


1  "  Quarta  causa  est  coitus  cum  sana,  cum  qua  de  proximo  coivit  infectus,  semine 
adhuc  in  matrice  exsistente."  Quoted  in  Hensler,  op.  citat. ,  p.  187. 

"Ibid.,  p.  171.  His  works  were  published  in  1515,  but  Beroaldus  died  ten  years 
before  this. 

3  He  flourished  toward  the  close  of  the  fifteenth  century.     The  date  given  is  that 
of  the  first  edition  of  his  works  which  I  have  found. 

4  Ibid.,  p.  197. 


HISTORY.  9 

that  laid  down  in  the  fifteenth  chapter  of  Leviticus,  although  his  account 
is  one  of  the  most  complete  that  we  have.  "Gonorrhoea,"  he  says,  "is 
an  involuntary  emission  of  semen.  The  external  cause  of  it  is  venereal 
passion  for  a  concubine  or  her  embraces."  "But  if  the  cause  be  internal 
its  seat  is  in  the  vessels,  the  members,  or  the  humors.  If  in  the  first  it  is 
because  they  are  too  hot  or  cold,  or  affected  with  paralysis  or  spasms.  If 
in  the  second  it  is  on  account  of  a  vice  in  the  nerves  or  sinews.  If  in  the 
third  the  humor  is  wrong,  either  in  quantity  or  quality.  The  patient 
knows  when  he  has  derived  it  from  an  external  source.  The  symptoms 
with  reference  to  its  internal  origin  are,  that  if  it  issue  from  the  other 
members  it  takes  place  without  erection  of  the  penis  and  escapes  insensi- 
bly ;  if  it  be  due  to  spasm  of  the  nerves  it  is  marked  by  pain  in  the  privy 
parts  and  groins.  If  it  arise  from  heat  it  is  relieved  by  cold  things  ;  when 
it  comes  from  heat  of  the  semen,  heat  and  biting  (mordicatio)  are  felt. 
Should  it  come  from  excess  of  semen  then  the  body  wastes  as  the  semen 
passes  sway.  If  due  to  the  moistness  and  watery  state  of  the  semen,  it 
soon  passes  away  when  it  falls  upon  the  clothes. 

Such  is  the  account  given,  not  by  an  obscure  author  or  low  charlatan, 
but  by  a  professor  at  Pisa,  so  renowned  then  as  a  cradle  of  letters  ;  and  I 
suppose  the  reader  will  agree  with  me,  that  it  is  difficult  to  imagine  how 
ignorance,  confusion,  and  assurance  could  go  much  farther.  The  author 
had  evidently  read  some  of  the  works  on  the  subject,  and  had  profited  by 
them  about  as  much  as  men  of  his  generation  were  wont  to  do.  It  is  true 
he  was  not  likely  to  learn  much  from  them,  as  most  of  them  only  repeat 
the  same  story,  but  if  they  had  been  capable  of  yielding  him  any  solid  in- 
formation, I  should  think  it  would  have  been  put  to  little  use  by  a  person 
in  such  a  state  of  bewilderment  as  t  o  assert  that  the  same  disease  arose 
from  the  vessels  being  too  hot  and  too  cold,  from  being  in  a  state  of  paral- 
ysis or  spasm.  Of  course  there  was  nothing  either  wonderful  or  criminal 
in  the  old  writers  being  ignorant  of  the  pathology  of  the  disease.  The 
fault  lay  in  their  not  having  the  moral  courage  to  say  so  ;  in  palming  off 
upon  their  readers  and  hearers  as  scientific  teaching  what  was  in  reality  a 
rigmarole  of  meagre  repetitions,  empty  words  and  baseless,  or  rather 
shameless,  assumption  of  knowledge  of  which  they  well  knew  they  were 
perfectly  destitute.  For  it  would  be  scarcely  going  too  far  to  say,  that  the 
stock  of  solid  information  possessed  by  a  few  of  them  about  the  very  sub- 
jects they  undertook  to  enlighten  the  world  upon,  was  not  much  larger  than 
that  of  the  old  Roman  philosophers,  whom  Juvenal  ridiculed  so  mercilessly, 
was  about  philosophy  itself  ;  and  the  statutes  of  Jean  de  Provence  in  1347, 
and  the  edicts  against  harboring  women  with  "  the  perilous  Infirmitie  of 
Brennynge,"  are  of  more  value  for  our  purpose  than  their  opinions  usually 
are. 

But  a  change  in  the  pathology  of  gonorrhoea,  a  change  destined  not 
•only  to  endure  for  ages  but  to  reach  our  day,  was  at  hand.  This  was  the 


10  ON    GONOKRHffiA. 

discovery  that  gonorrhoea  was  really  a  form  of  venereal  disease,  or  to  adopt 
the  ideas  and  language  of  by-gone  days,  a  variety  of  syphilis.  The  dis- 
covery was  reserved  for  the  eagle  glance  of  Paracelsus,  who,  braggart, 
buffoon,  and  charlatan  as  he  was,  possessed  almost  superhuman  powers  of 
penetration,  and  I  quite  agree  with  Simon  of  Hamburg  when  he  says,  that 
we  must  stand  astounded  at  the  keenness  of  his  view.  He  at  once  arrayed 
gonorrhoea  among  the  forms  of  syphilis,  and  when  we  consider  that  this 
doctrine  survived  the  experiments  of  Bell  and  Balfour  :  that  it  was  upheld 
by  such  men  as  Hunter  and  his  followers  ;  and  that  the  belief  in  a  syphi- 
litic gonorrhoea  is  not  extinct  in  our  time,  we  must  admit  that  the  step 
taken  by  Paracelsus,  pregnant  as  it  was  with  error,  was  yet  the  first  ever 
taken  in  the  right  direction,  and  the  greatest  till  we  come  to  the  days  of 
inoculation.  James  Bethencourt,  too,  got  very  near  the  truth  when  he 
spoke  of  a  gonorrhoea,  for  which  he  was  consulted,  as  a  discharge  of  "  a 
sanious  and  virulent  Matter,"  "  contracted  by  Venery."  But  their  teach- 
ings do  not  seem  to  have  been  foUowed  up,  and  indeed  to  have  on  one 
point  rather  fallen  into  desuetude,  for  we  find  Astruc  some  two  centuries 
later  telling  his  readers,  that  in  venereal  gonorrhoea  there  is  always  a  large 
and  lasting  discharge  of  purulent  semen. 

I  have  not  been  able  to  make  out  what  author,  after  the  long  silence 
from  1532  to  1563  which  Hensler  speaks  of,  renewed  the  knowledge  of 
gonorrhoea.  I  suppose  Petronius,  1565,  may  claim  to  be  the  first,  after 
which  date  the  disease  can  be  traced  through  a  long  succession  of  writers, 
whose  number  gradually  increases  as  their  date  approaches  our  own. 
Prominent  among  these  are  Csesalpinus,  1602,  Martiniere,  1644,  Sydenham, 
about  1680,  Musitanus,  1697,  Devaux,  1711,  Turner,  1717,  and  Cockburn, 
1728.  From  this  time  all  interest  in  its  history  ceases,  as  after  that  gon- 
orrhoea figures  largely  in  general  medicine  and  surgery.  Judging  from 
the  total  silence  of  later  writers  about  any  opposed  views,  it  seems  a  legiti- 
mate inference  that  whoever  again  attracted  notice  to  it,  adopted  on  other 
points  the  pathology  of  Paracelsus,  and  that  by  unanimous  suffrage  gonor- 
rhoea remained  incorporated  with  syphilis  till  the  time  of  Cockburn,  quite 
two  centuries  later.  And  even  a  century  after  that,  the  fatal  teaching  of 
Hunter,  the  prestige  which  his  commanding  genius  imparted  to  every- 
thing he  said,  still  made  belief  in  the  identity  of  the  two  diseases  the  rul- 
ing tenet  of  the  day  ;  the  arguments  of  Cockburn  and  the  experiments  of 
Bell,  Balfour,  and  Hernandez  counting  for  nothing  against  his  dictates. 
Even  now,  notwithstanding  the  luminous  teaching  of  Ricord,  belief  in 
their  identity  is  not  entirely  given  up  by  some  writers  and  practitioners. 

Nor  have  I  been  more  successful  in  my  attempts  to  find  out  who  is  re- 
sponsible for  the  long  prevalent  error,  that  gonorrhoea  is  a  critical  flow, 
with  which  art  ought  not  to  meddle  too  much  ;  an  error  so  widely  spread 
that  the  profession  of  it,  a  few  years  ago,  as  an  article  of  faith,  by  a  physi- 
cian and  a  surgeon,  each  attached  to  a  large  general  hospital  in  London, 


HISTORY.  1 1 

elicited  no  remark  in  the  medical  journals.  I  suppose,  however,  that  those 
who  have  studied  the  subject,  and  whose  opinions  alone  are  worth  consid- 
eration, are  now  agreed  that  gonorrhoea  is  an  unmixed  evil,  that  the  dis- 
charge carries  off  nothing  but  itself,  and  that  the  more  there  is  of  it  the 
more  suffering  and  risk  for  the  patient. 

I  have  long  suspected  that  till  about  the  beginning  of  thfe  eighteenth 
century  gonorrhoea  was  rare,  and  only  an  occasional  visitor  in  western 
Europe.  Among  other  reasons  I  may  mention  the  long  periods  of  silence 
about  it  observed  by  writers  on  venereal  disease  in  the  first  three  quarters 
of  the  sixteenth  century  ;  the  absence  of  all  allusion  to  it  by  the  lay  writers 
like  Shakespeai'e  who  followed  close  upon  them,  and  who  are  yet  so  liberal 
in  their  notice  of  syphilis  ;  the  utter  ignorance  of  the  complaint  displayed 
by  the  leading  medical  authority  of  the  latter  part  of  the  seventeenth  cen- 
tury, in  England,  Sydenham,  who  I  should  think  could  never  have  seen  a 
case  of  the  disease,  or  surely  he  could  not  have  written  an  account  of  it  so 
confused,  that  had  it  emanated  from  an  obscure  author  like  Martin  or 
Profily,  it  would  have  been  censured  as  the  product  of  barefaced  empiri- 
cism. And  that  the  lay  writers  of  those  times  were  not  deterred  from 
mentioning  gonorrhoea  by  the  nature  of  the  topic,  is,  I  think,  clearly 
shown  by  the  fact  that  we  find  the  pious  and  moral  Johnson  speaking  of  it 
in  the  plainest  terms.  The  last  reason  I  would  urge  is,  that  having  had 
the  opportunity  of  tracing  this  disease  for  many  years  back,  in  what  was 
then  a  very  small  town  in  the  north  of  England,  where  gonorrhoea  is  now 
rather  firmly  established  owing  to  the  growth  of  the  place,  I  was  able,  by 
means  of  the  books  of  a  successive  line  of  surgeons,  kept  for  a  long  time, 
to  make  out  pretty  certainly  that  in  their  practice  it  had,  till  about  forty 
years  ago,  only  been  very  rarely  seen  and  sometimes  not  heard  of  for  years 
together.  All  the  inquiry  I  could  make  tended  to  fortify  this  opinion ; 
the  general  experience  seemed  to  be  that  gonorrhoea  always  died  out  soon 
after  it  was  acquired,  and  did  not  spread,  the  horror  of  communicating  it 
having  perhaps  greater  weight  then  than  now.  This  feeling,  only  too 
often  deadened  amidst  the  dissipation  of  larger  places,  possibly  long  oper- 
ated as  a  check  upon  the  spreading  of  a  disease  infecting  only  by  sexual 
intercourse  ;  while  syphilis,  conveyed  by  unsuspected  routes,  and  often  by 
modes  impossible  of  prevention,  long  gained  ground  with  greater  speed. 


CHAPTER  II. 

PATHOLOGY. 

UNDER  the  term  gonorrhoea  I  propose  to  include  all  purulent  discharges 
due  to  connection,  or  to  the  contact  of  infecting  matter  originally  secreted 
by  the  mucous  surfaces  of  the  genital  and  urinary  passages,  and  reprodu- 
cing the  same  disease  in  another  person,  who  can  again  give  it  to  a  third. 

As  I  have  seen  reason  to  doubt  some  of  the  conclusions  arrived  at  by 
certain  eminent  specialists  in  respect  to  the  pathology  of  this  disorder,  I 
take  the  liberty  of  stating  the  grounds  for  dissent.  To  do  so  effectually, 
however,  it  will  be  necessary  to  go  somewhat  into  detail.  This  is  unavoid- 
able where  accuracy  is  aimed  at.  General  statements  may  serve  very  well 
as  the  staple  mode  by  which  opinions  are  communicated,  but  they  are 
easily  met  by  denials  of  the  same  nature.  Minuteness  will  not  allow  of 
this.  By  narrowing  the  subject  under  examination,  it  reduces  it  more  to 
a  form  which  admits  of  demonstration,  and  thus  really  shortens  a  discus- 
sion which,  under  a  looser  system,  might  become  endless. 

Genesis  of  Gonorrhoea.  A,  In  the  Male. — As  regards  gonorrhoea  in  the 
male  sex,  the  most  practical  division  of  the  affections  lumped  together 
under  this  name,  or  that  of  blennorrhagia,  seems  to  be  the  separation  of 
them  into : — 1.  Cases  resulting  from  connection  with  a  female  suffering 
under  gonorrhoea,  or  gleet.  2.  Those  which  ensue  from  intercourse  with 
a  woman  laboring  under  any  form  of  discharge  not  due  to  connection, 
such  as  leucorrhcea, '  menstruation,3  an  unhealthy,  irritable  state  of  the 
vagina,  malignant  disease  of  the  os  or  cervix  uteri,  simple  excoriation  or 
ulceration  of  these  parts,  uterine  catarrh,  or  even  a  person  in  whom  these 
organs  are  in  a  perfectly  healthy  state.3  3.  Those  arising  from  errors  of 
diet,  from  drinking  beer,  the  use  of  asparagus,  and  certain  other  articles 
of  food,  blows,4  violent  exercise,  sue  has  galloping  on  a  bare-backed  horse 
excessive  work,  hard  travelling,6  erotic  excitement,  over-indulgence  in 

1  The  Practice  of  Medicine,  vol.  i.,  p.  306.     By  Thomas  Hawkes  Tanner.  1869. 
*  On  Urethritis  and  Syphilis,  p.  25.     By  William  Henry  Judd.   1836. 
a  Swediaur  :  Practical  Observations  on  Venereal  Complaint,  p.  41.     1788.    Ricord: 
Lettres  sur  la  Syphilis,  pp.  50  and  51.     1863. 

4  Diseases  of  the  Genito-Urinary  Organs,  p.  36.     By  Henry  James  Johnson.  1851. 
6  Judd:    Op.  citat.,  p.  33. 


PATHOLOGY.  13 

sexual  pleasures,  protracted  attempts  at  connection  under  the  influence  of 
wine,1  late  hours,2  direct  application  of  irritants,3  the  presence  of  calculus, 
and  finally  the  suppression  of  cutaneous  eruptions ;  the  remainder  of  the 
thirty-seven  causes  to  which  gonorrhoea  is  ascribed  4  being  left  over  for 
the  present. 

Strictly  speaking,  the  cases  in  the  third  class  hardly  belong  to  the  sub- 
ject in  hand,  as,  with  one  or  two  exceptions,  they  are  not  due  to  connection 
at  all,  and  these  exceptions  are  not  counted  as  instances  in  which  conta- 
gion is  communicated.  But  as  they  are  often  called  by  the  same  name, 
and  as  every  such  disorder  seems  to  be  considered  by  some  authors  a  very 
probable  cause  of  discharge  in  the  other  sex,  they  cannot  well  be  omitted. 

1.  The  question  as  to  the  power  of  the  first  class  of  agents  to  bring  on 
gonorrhoea  in  the  male  sex  may,  I  suppose,  be  regarded  as  so  completely 
settled,  that  it  would  be  wasting  the  reader's  time  to  dwell  on  the  topic. 
Those  in  the  second  class  deserve  more  attention. 

2.  The  first  step  is  to  clear  them  from  an  overlying  stratum  of  some- 
what loose  assertion.     It  is  constantly  assumed  as  incontrovertible,  that  a 
female,  having  any  one  of  the  affections  in  this  category,  may  communicate 
gonorrhoea  to  a  man  who  has  connection  with  her,  a  doctrine  more  than 
once  of  late  years  proclaimed  as  a  discovery,  particularly  by  the  late  Mr. 
Skey.     With  all  deference  to  those  who  hold  this  view,  I  am  inclined  to 
say  that  the  fact  has  in  some  cases  been  admitted  on  insufficient  grounds  ; 
that  it  has  been  accepted  without  such  a  foregoing  knowledge  of  the  pa- 
tient's history,  and  searching  examination  of  the  persons  concerned,  as 
could  alone  justify  our  looking  upon  it  as   irrefragably  established,  and 
that  many  histories  of  gonorrhoea  thus  set  up  are  open  to  grave  suspicion. 
One  strong  argument  in  support  of  such  doubts  is,  that  only  too  often  an 
old  gleet,  or  a  disposition  to  it,  is  oveiiooked  ;  irrespective  of  this,  we  fre- 
quently find  that  a  patient  who  comes  with,  very  plausible  reasons  for  hav- 
ing acquired  a  discharge  in  this  way,  afterwards  changes  his  mind  of  his 
own  accord.     Still,  after  allowing  for  this  source  of  error,  cases  remain 
which  merit  inquiry,  and  these  I  propose  to  examine. 

Simple  inflammation  of  the  vulva,  accompanied  by  purulent  discharge 
(acute  or  subacute  vulvitis),  not  of  course  due  to  connection,  seems  at  first 
sight  one  of  the  most  likely  causes,  but  I  have  not  met  with  a  single  in- 
stance of  gonorrhoea  thus  communicated.  What  is  more,  I  have  seen  vul- 
vitis set  up  by  connection  take  on  a  pretty  severe  form,  and  yet  a  patient, 
quite  liable  to  gonorrhoea,  cohabiting  with  a  girl  thus  situated,  has  es- 
caped. Among  other  cases  I  may  give  the  following  : — 

1  Lancet,  vol.  i.,   p.  211.     1851. 

2  Nouveau  Traite   des   Maladies   Veneriennes,  p.   61.      Par  le   Docteur   Melchior 
Robert.     1861. 

3  Swediaur  :  Op.  citat. ,  p.  38. 

4  Nouveau  Dictionuaire  de  Medecine,  tome  v.,  p.  131.     1866. 


14  ON    GONORRHOEA. 

I  was  consulted  in  the  summer  of  1874,  by  Mr.  F ,  for  what  he 

called  gleet.  He  was  thin,  nervous,  delicate,  and  afflicted  with  a  strong 
tendency  to  dyspepsia.  He  had  suffered  from  gonorrhoea,  followed  by 
gleet ;  there  was,  however,  now  no  discharge  from  the  urethra,  neither 
had  there  been  any  for  some  time.  A  few  small  shreds  passed  occasionally 
in  the  urine,  and  the  canal  was  tender.  I  recommended  passing  a  bougie 
once  a  week,  and  if  that  did  not  set  matters  right,  a  weak  nitrate  of  silver 
injection.  Some  time  after  this  he  contracted  an  illicit  connection  with  a 
girl  who,  for  all  I  could  make  out,  seemed  never  to  have  had  any  disease. 
The  entrance  to  the  vagina  was  narrow,  and  connection  was  difficult.  It 
was  followed  by  soreness  of  the  vulva,  accompanied  by  muco-purulent  dis- 
charge ;  yet,  though  connection  went  on  till  she  could  bear  it  no  longer, 
on  account  of  the  pain  it  occasioned,  this  gentleman  had,  according  to  his 
own  repeated  statement,  no  symptoms  of  infection  ;  certainly  when  he 
called  upon  me  he  was  free  from  anything  of  the  kind.  Now  if  these 
discharges  really  possess  an  infecting  power  equal  to  that  of  gonorrhoea, 
which  is  the  only  construction  we  can  put  upon  the  opinions  expressed  by 
many  authors,  how  comes  it  that  men  escape  under  such  circumstances  ? 

About  the  probability  of  leucorrhcea,  by  which  name  I  understand  ca- 
tarrhal  inflammation  of  the  vagina,  being  a  frequent  cause  of  gonorrhoea 
in  the  male,  I  confess  myself  somewhat  incredulous.  In  a  man  who  has 
married,  as  many  do  marry,  without  being  thoroughly  cured  of  a  gleet,  or 
even  tenderness  in  parts  of  the  urethra,  leucorrhcea,  especially  if  it  take  on 
the  more  serious  form  of  inflammatory  vaginitis,  may  light  up  the  slumber- 
ing embers  of  disease.  But  I  am  disposed  to  think  it  is  the  connection 
and  excitement  that  do  this,  and  to  rate  the  infecting  power  of  leucorrhcea 
low  even  here,  and  still  more  so  in  the  case  of  a  healthy  man,  and  I  have 
seen  reason  to  believe  that  men  liable  enough  to  gonorrhoea  expose  them- 
selves with  impunity  to  the  contagion  of  leucorrhcea.  I  had  under  my 
care  a  patient  who  was  particularly  susceptible  of  the  former  complaint, 
yet  he  had  connection  over  and  over  again  with  a  girl  who  was  scarcely 
ever  quite  free  from  leucorrhcea,  without  ever  displaying  a  sign  of  con- 
tamination. I  have,  too,  seen  pretty  good  evidence  that  a  man  may  have 
intercourse  with  a  woman  in  the  early  stage  of  the  more  inflammatory 
form  of  vaginitis,  a  period  when  gonorrhoea  is  sometimes,  if  not  always, 
highly  infectious,  and  yet  contract  no  disease. 

Mrs.  E ,  a  healthy-looking  woman,  about  thirty-six  years  old,  con- 
sulted me,  June  4,  1872,  about  a  discharge  which  she  said  she  had  caught 
from  her  husband.  She  was  suffering  from  rather  plentiful  greenish-yellow 
secretion,  and  some  vulvo-vaginitis,  accompanied  by  great  heat  and  sore- 
ness of  the  parts,  pain  on  walking  or  long  standing,  etc.  She  had  only  been 
married  a  fortnight,  and  was  greatly  distressed.  On  learning,  however, 
from  her,  by  cross-questioning,  that  she  had  no  ground  for  suspecting  her 
husband  beyond  the  symptoms  just  mentioned,  and  that  his  conduct  did 


PATHOLOGY.  15 

not  seem  to  be  in  any  way  incorrect,  or  to  have  been  so  prior  to  marriage, 
I  thought  it  might  be  wiser  to  defer  giving  any  positive  opinion,  as  pos- 
sibly the  affection  was  due  merely  to  intercourse,  which  had  called  a  mor- 
bid disposition  of  the  parts  into  play,  for,  though  healthy  in  appearance, 
she  was  not  strong.  Meanwhile,  I  prescribed  a  lead  lotion  and  saline  mix- 
ture, which  soon  stopped  the  discharge. 

On  March  30,  1873,  she  again  consulted  me.  She  had  remained  free 
from  discharge  till  quite  recently,  but  her  health,  which  had  improved  du- 
ring the  summer,  had  begun  to  fail  as  far  back  as  October,  since  which 
time  she  had  suffered  from  dyspepsia  and  some  degree  of  bronchitis,  ac- 
companied by  severe  cough.  Latterly,  the  discharge  had  re-appeared.  I 
inquired  very  carefully  into  the  husband's  case,  and  found  that  on  this,  as 
on  the  previous  occasion,  cohabitation  had  been  kept  up  till  her  symptoms 
had  set  in.  Notwithstanding  this,  she  had  observed  no  sign  of  infection 
in  him,  though  she  had  been  inquisitive  enough  on  the  point,  neither  had 
she  found  any  farther  reason  to  believe  that  he  was  infected  at  the  time  of 
marriage. 

In  this  case,  then,  which  is  only  a  specimen  of  what  I  suppose  most 
practitioners  have  repeatedly  seen,  there  is  good  ground  for  thinking  that 
the  husband  remained  free  from  disease,  whereas,  had  his  wife  been  suffer- 
ing from  an  affection  equally  as  contagious  as  gonorrhoea,  he  could  hardly, 
when  taking  no  precautions,  have  exposed  himself  so  many  times  to  danger 
and  have  got  off  safe.  We  hear,  indeed,  of  men  who  visit  women  of  the 
town  constantly  without  using  any  means  of  prevention,  and  still  manage 
to  steer  clear  of  disease.  Perhaps  we  hear  a  little  more  than  the  truth,  or 
at  any  rate  what  is  calculated  to  mislead  us,  seeing  that,  if  I  am  to  judge 
from  what  I  have  heard  of  later  experiences  of  such  a  nature,  scarcely  one 
man  escapes  in  the  long  run  ;  if  any  do,  they  are  exceptions  on  which  no 
law  can  be  based.  Many  husbands  must,  when  their  wives  are  beginning 
to  suffer  from  leucorrhoea,  continually  run  this  risk,  and  yet  most  of  those 
so  placed  never  have  anything  like  true  gonorrhoea. 

Nor  do  I  stand  alone  in  my  incredulity.  Dr.  Durkee,  who  has  had 
large  experience  in  these  diseases,  is  as  hard  of  belief  as  I  am.1  His  own 
opinion,  he  says,  coincides  with  that  of  Sigmund,  that  gonorrhoea  alone 
produces  gonorrhoea  ;  an  opinion  shared  to  the  fullest  by  Bonniere  and 
Gosselin,  and  almost  as  fully  by  Cullerier.2  Auspitz,  too,  in  a  work  dis- 
tinctly devoted  to  the  study  of  venereal  contagion,  says 3  that  the  balance  of 
evidence  is  in  favor  of  there  being  a  specific  virulence  in  gonorrhoea  ;  tes- 
timony at  least  equal  in  value  to  some  of  the  frivolous  anecdotes  on  which 
the  non-specific  theory  of  the  disease  is  based. 


1  A  Treatise  on  Gonorrhoea  and  Syphilis,  p.  17.     1864. 

8  Nouvean  Dictionnaire  de  Medicine,  tome  v.,  p.  132.    1866. 

3  Die  Lehre  vom  Syphilitischen  Contagiuna,  S.  68.     1866. 


16  ON    QONORRHCEA. 

The  argument  that,  though  contagion  proves  the  presence  of  a  poison 
in  gonorrhoea!  secretion,  it  still  does  not  show  that  this  poison  is  specific 
and  incapable  of  being  produced  by  simple  inflammation,  became  a  muco- 
purulent  conjunctivitis,  so  strictly  analogous  to  gonorrhoea,  the  inflamma- 
tion originates  in  simple  causes,  and  yet  sets  up  a  secretion  which  is  con- 
tagious and  can  be  inoculated  upon  a  series  of  persons,  is  of  very  doubtful 
value.  In  the  first  place,  in  some  of  the  cases  relied  on  as  evidence,  the 
affection  was  pretty  clearly  not  simple  but  strictly  specific  at  the  very  out- 
set, as  much  so  as  any  epidemic.  Secondly,  I  presume  the  supporters  of 
this  doctrine  will  scarcely  maintain  that  chancroid  is  not  specific,  while 
they  at  the  same  time  accept  the  case  related  by  Dr.  Taylor,  whose  great 
reputation  is  a  guarantee  for  the  accuracy  of  the  history,  as  showing  that 
chancroid  may  spring  from  a  simple  affection. 

Dr.  Bumstead  quotes l  from  Dr.  Fordyce  Barker  a  brief  description  of 
a  disease  affecting  the  interior  of  the  womb,  which,  while  quite  innocently 
acquired,  is  capable  of  producing  purulent  discharge  in  the  male.  Dr. 
Barker  considers  it  to  be  a  peculiar  inflammation  of  the  lining  membrane 
of  the  uterus,  under  the  influence  of  which  the  secretion  loses  its  natural 
alkaline  reaction  and  becomes  acid  and  acrid,  as  a  consequence  of  which  it 
irritates  and  excoriates  the  mucous  membrane  of  the  vulva.  He  has  re- 
peatedly known  this  state  induce  uretbritis  in  the  male. 

One  case  would  have  been  enough  if  it  had  been  shown  that  the  disease, 
thus  originated,  was  not  simple  urethritis,  but  real  gonorrhoea  accompanied 
by  chordee,  swelled  testicle,  irritable  bladder,  sympathetic  pains,  and  so 
on  ;  and  especially  that  it  was  capable  of  giving  rise  to  identically  the 
same  affection  in  another  person.  But  unless  the  evidence  be  to  this 
effect,  it  is  beside  the  question  so  far  as  identity  is  concerned.  "We  want 
to  know,  not  whether  such  a  state  of  the  uterine  system  will  set  up  dis- 
charge in  the  male,  for  that  might  be  granted,  but  what  the  nature  of  that 
discharge  is.  The  belief  in  the  specific  nature  of  gonorrhoea  will  receive  a 
rude,  if  not  a  fatal,  shock,  when  it  is  shown  that  an  acid  state  of  the  uterine 
mucus  produces  the  same  results  as  the  laudable  pus  of  gonorrhoea,  and 
the  curdled  albuminous  discharge  of  leucorrhoea,  formed  by  the  mingling 
of  the  free  alkaline  secretion  from  the  glands  lining  the  cervix:  uteri  with 
the  complex  acid  of  the  vaginal  fluid. 

Admitting  that  urethra!  discharges  do  appear  in  men  as  the  result  of 
connection  with  women  laboring  under  leucorrhoea,  in  whom  there  is  no 
reason  for  suspecting  a  present  or  previous  blennorrhagia,  it  must,  I  think, 
be  equally  admitted  that  the  facts  supposed  to  establish  this  are,  when  we 
come  to  sift  the  matter  closely,  generally  vague  and  few ;  and  in  no  in- 
stance that  I  have  read  of  is  there  anything  to  show  that  the  surgeon  had 
satisfied  himself  as  to  the  previous  state  of  the  organs  in  both  persons,  yet 

1  The  Pathology  and  Treatment  of  Venereal  Diseases,  p.  63.    1866. 


PATHOLOGY.  17 

•without  such  evidence  belief  must  remain  mere  conviction  ;  it  cannot  be 
raised  to  the  stability  of  a  truth.  Whether  it  be  the  first  infection,  or  one 
of  many,  and  in  whatever  kind  of  constitution  it  may  occur,  a  discharge 
thus  set  up  is,  I  must  repeat,  usually  much  milder  than  gonorrhoea  in  its 
symptoms,  and  rarely  inveterate  in  its  nature.  But  the  infecting  power  of 
the  latter  disease  is  a  matter  of  every-day  experience  ;  it  can  be  demon- 
strated by  experiment ;  severity,  at  the  first  infection  at  any  rate,  is  the 
rule  rather  than  the  exception,  and  out  of  many  cases  some  are  sure  to  be 
obstinate  ;  infection  is  almost  a  certain  result  when  no  precautions  are 
taken  to  guard  against  it ;  and  lastly,  this  infection  may  be,  and  is,  re- 
produced to  almost  any  extent,  even  under  much  the  same  circumstances 
which  seem  to  interfere  very  materially  with  the  diffusion  of  it  from  the 
first-named  class  of  causes.  Moreover,  those  who  support  the  prevailing 
view,  seem  not  to  notice  one  point  which  involves  something  like  a  contra- 
diction or  an  inconsistency.  It  is  at  once  conceded  that  a  man  who  .gets 
gonorrhoea  from  a  prostitute,  has  derived  it  from  the  same  disease  in  her ; 
but  only  too  often,  in  narratives  of  infection  due  to  other  kinds  of  illicit 
connection,  a  deus  ex  machind  must  be  evoked  to  clear  up  the  mystery. 

I  suppose  most  medical  men  have  heard  of  cases  where  discharge  from 
the  urethra  resulted  from  connection,  when  there  was  no  reason  to  believe 
that  the  female,  supposed  to  have  communicated  the  disease,  had  ever  been 
infected.  One  patient,  whose  truthfulness  I  never  saw  any  reason  to  doubt, 
assured  me  that  he  had  three  times  attempted  to  keep  up  connection  with 
his  wife,  and  had  on  each  occasion  been  obliged  to  desist  owing  to  gonor- 
rhoea coming  on. 

But  even  supposing  such  an  affection  were  genuine  gonorrhoea,  the 
evidence  would  count  for  nothing  unless  the  previous  history  of  the  par- 
ties, and  especially  of  the  husband,  was  carefully  investigated.  Few  facts  in 
the  pathology  of  this  disease  are  more  certain,  than  that  a  slightly  inflamed, 
sensitive  state  of  the  urethra  may  remain  for  many  years  uncured,  and  not 
revealing  its  existence  by  any  visible  sign,  and  yet  upon  the  stimulus  of 
connection  with  even  a  perfectly  healthy  woman  develop  at  once  into  a 
purulent  running.  That  true  gonorrhoea,  however,  was  ever  thus  set  up  in 
a  man  never  previously  infected,  I  must,  judging  from  experience,  respect- 
fully decline  to  believe.  In  every  case  such  a  gonorrhoea,  when  I  have  seen 
it,  ran  a  different  course  from  the  genuine  complaint.  It  may  have  some- 
times resembled  a  mild  attack  of  the  latter,  never  a  severe  one. 

If  the  prevailing  theory,  too,  be  correct,  how  does  it  happen  that,  in 
every  case  of  very  severe  results  from  gonorrhoea,  swiftly  progressing  retrac- 
tile stricture,  bad  swelled  testicle,  cystitis,  inflammation  and  suppuration 
in  the  prostate  and  seminal  vesicles,  severe  gonorrhoea!  rheumatism,  and 
the  serious  complications  of  this,  pyaemia  and  endocarditis  ;  in  gonorrhoeal 
peritonitis,  phlegmonous  inflammation  and  nephritis,  we  always  find,  when 
there  is  a  history  at  all,  one  of  distinct  gonorrhoeal  infection? 
2 


18  ON    GONORRHCEA. 

Numerous  histories  of  cases  are  to  be  found,  showing,  in  the  opinion 
of  those  who  relate  them,  that  gonorrhoea  can  be  innocently  generated. 
I  believe  these  accounts  are  put  forward  in  all  good  faith  ;  but  while  I  un- 
reservedly admit  the  veracity  of  the  authors  of  them,  I  demur  to  their  con- 
clusions. I  do  not  say  that  gonorrhoea  never  arises  in  this  way,  but  that 
they  have  not  proved  that  it  does  so.  Possibly  enough  they  may  be  quite 
right  and  I  may  be  as  far  wrong  ;  my  contention  is  that  their  evidence  does 
not  go  so  far  as  they  assume.  Their  cases  are,  no  doubt,  numerous  ;  but 
unless  the  issues  can  be  narrowed  to  points  bearing  vitally  on  the  question, 
unless  the  cases  are  individually  so  convincing  as  to  count  for  positive  tes- 
timony, they  carry  no  more  weight  collectively  than  singly ;  merely  adding 
to  the  bulk  of  weak  evidence  will  not  do  away  with  the  radical  vice  of  its 
quality.  "When  it  can  be  shown,  in  even  a  very  few  instances,  that  both 
persons  could  be  proved  to  have  been  free  from  all  previous  disease  at  the 
time  when  the  gonorrhoea  was  thus  engendered,  then,  I  apprehend,  the 
believers  in  its  specific  nature  must  give  up  the  cause  for  lost.  Till  then, 
I  think  we  are  justified  in  assuming  that,  so  far  as  the  evidence  on  behalf 
of  leucorrhcea  is  concerned,  the  matter  by  which  gonorrhoea  is  communi- 
cated may  be  of  as  specific  a  nature  as  the  lymph  of  the  cow-pox  vesicle,1 
and  that  the  supply  of  the  infecting  material  is  kept  up  in  the  same  way  in 
both  cases — namely,  by  propagation  from  individual  to  individual.  Of 
course,  this  does  not  mean  asserting  that  it  is  never  generated  spontan- 
eously in  the  female ;  possibly  such  may  be  the  case  at  times.  The  disease 
must  have  begun  with  some  individual,  and  accordingly  there  is  nothing 
so  very  improbable  in  its  beginning  again  in  the  same  way.  Neither  is  it 
impossible  that  a  simple  leucorrhcea  or  vaginitis  may,  by  some  peculiar 
state  of  the  health,  be  intensified  into  a  contagious  form.  We  are,  after 
all,  dealing  to  a  great  extent  with  probabilities,  and  I  am  as  ready  to  accept 
the  new  doctrine  when  it  can  be  proved  to  be  the  more  probable  of  the 
two,  as  I  am  at  present  to  abide  by  my  own. 

During  a  four  years'  apprenticeship  to  a  surgeon,  who,  though  living  in 
a  very  small  town,  had  one  of  the  largest  practices  in  Cumberland,  I  saw 
but  very  few  cases  of  gonorrhoea,  certainly  not  a  dozen,  though  every  in- 
stance of  such  a  disease  must  have  come  to  my  knowledge.  Of  these,  I 
know  that  some  were  caught  from  sources  foreign  to  the  place,  being  either 
contracted  in  a  large  town,  or  from  intercourse  with  some  strolling  player- 
girl,  or  some  young  woman  who  had  recently  been  in  a  large  town  ;  and 
this  might  easily  have  been  the  case  with  the  others,  as  girls,  known  to  be 
of  loose  character,  though  not  avowed  prostitutes,  of  whom  there  were  only 

1  ' '  The  common  cause  [of  gonorrhoea]  is  the  application  of  gonorrhoeal  matter  during 
sexual  intercourse.  Although  the  existence  of  this  animal  poison  has  only  been  in- 
ferred from  the  effects,  yet  there  can  be  little  doubt  that  there  is  such  a  poison  of  a 
special  nature,  and  that  it  does  not  arise  simply  from  indiscriminate  sexual  inter- 
course."— Tanner:  Op.  citat.,  vol.  i  ,  p.  306. 


PATHOLOGY.  19 

iwo  or  three  in  the  place,  were  every  now  and  then  returning  home  from 
such  parts.  I  had  ample  means  of  knowing  that  this  paucity  of  gonorrhoea 
cases  occurred  also  in  the  practice  of  other  medical  men.  Yet  the  town 
ought  to  have  furnished  its  quota  of  gonorrhoea,  for  certainly  the  morals 
of  the  lower  classes,  and  indeed  of  all  the  young  men  as  a  rule,  were  as  lax 
in  respect  to  connection  as  they  could  be,  and  I  never  heard  of  any  person 
taking  precautions  against  infection  ;  every  one,  lay  and  medical  alike,  be- 
lieving that  the  disease  was  always  imported.  In  a  paper  by  Dr.  Rocchi,1 
comment  is  made  upon  the  fact  that  this  is  noticed  also  in  Italy,  gonorrhoea, 
except  when  imported  from  some  populous  part,  being  quite  unheard  of  in 
the  country  places,  where  yet  the  conditions  mentioned  by  Eicord,  and 
those  who  support  him,  as  requisite  for  its  generation  are  present,  especi- 
ally during  the  heat  of  summer,  and  among  a  class  of  people  not  remark- 
able for  cleanliness. 

The  microscope,  from  which  we  might  fairly  expect  help,  leaves  us 
completely  in  the  lurch.  According  to  Dr.  Tyler  Smith,2  it  shows  the 
products  of  gonorrhoea  in  the  female,  and  of  leucorrhoea  springing  up 
spontaneously,  but  capable  of  giving  urethritis  to  the  male,  to  be  almost 
identical.  But  then,  on  the  same  showing,  there  may  yet  be  a  very  marked 
difference  ;  for  there  is  no  positive  distinction  between  the  discharge  of 
leucorrhoea  "  accompanied  by  sterility,"  and  that  "  attended  by  the  usual 
aptitude  for  impregnation,"  conditions  evidently  thought  by  Dr.  Tyler 
Smith  himself  to  be  widely  distinct. 

This  gentleman,  whose  painstaking  researches  and  cautious  inductions 
entitle  all  he  says  to  our  respect  and  confidence,  gives 3  an  account  which 
is  calculated  to  make  us  pause  -  before  accepting  the  modern  doctrine.  Al- 
though he  defers  to  M.  Ricord's  authority,  although  he  starts  with  an  ex- 
pressed wish  to  find  evidence  that  gonorrhoea  may  be  generated  by  leu- 
corrhoea, his  strong  love  of  truth  compels  him  to  leave  the  question  unde- 
cided. He  had  great  opportunities  of  observation  ;  he  was  ably  assisted  ; 
he  tells  us  that  it  was  his  habit  to  interrogate  the  husband  strictly  about 
his  early  days  ;  he  did  not  forbid  connection  when  the  wife  was  suffering 
from  leucorrhoea  unless  the  symptoms  were  very  severe  ; 4  yet  all  his  experi- 
ence only  furnished  one  case  of  infection,  and  that  one  very  incomplete. 
He  tells  us  that  a  lady,  in  whom  epithelial  leucorrhoea  arose  spontaneously, 
gave  her  husband  urethritis,  and  afterward  blennorhagia,  but  there  is  not  a 
single  word  to  show  what  the  course  and  symptoms  were  in  either  attack. 

In  order  to  follow  up  this  part  of  the  argument,  I  will  give  two  instan- 
ces showing,  it  seems  to  me,  the  contagious  nature  of  true  gonorrhoea,  one 
in  its  rise,  the  other  in  its  decline  ;  and  I  think,  taking  all  the  facts  to- 
gether, that  they  fairly  represent  somewhat  common  occurrences. 

1  Giornale  italiano,  vol.  ii.,  p.  196.    1871. 

-  Pathology  and  Treatment  of  Leucorrhoea,  p.  133.    1854. 

3  Op.  Citat.,  p.  126.  40p.  Citat.,  p.  213. 


20  ON    GONORRHOEA. 

A  young  girl,  of  respectable  family,  formed  an  illicit  connection  with  a 
gentleman  who,  after  a  time,  gave  her  gonorrhoea.  This  was  her  first 
wrong  step.  Before  she  became  aware  that  there  was  anything  amiss  with 
her,  she  had  connection  with  a  relative,  a  man  holding  a  good  post  in  a 
public  office,  and  who  was  very  much  attached  to  her.  She  had  gonor- 
rhoea in  a  severe  and  obstinate  form,  and  her  relative  had  the  same  disease, 
accompanied  by  gonorrhoea!  rheumatism  ;  in  the  end,  he  too  got  quite  well 
All  intercourse  with  the  first  paramour  was  at  once  broken  off,  but  I  did 
not  feel  so  sure  that  the  connection  with  the  second  ceased  entirely.  Some 
months  after  this  she  had  connection,  once,  with  a  man  whom  she  met  at  a 
ball,  at  least  this  was  her  version  of  the  story,  and  very  shortly  after  with 
her  relation.  Three  or  four  days  after,  she  came  to  me  in  great  alarm  at 
finding  herself  again  infected.  She  had,  in  the  interim,  met  her  ball-room 
friend,  and  violently  upbraided  him.  He  did  not  deny  the  fact  of  previous 
infection,  but  justified  himself  by  saying  that  he  quite  believed  there  was 
nothing  left  of  his  complaint  to  do  any  mischief.  Within  two  hours  after 
her  visit  I  was  consulted  by  her  relative  for  what  was  evidently  the  begin- 
ning of  a  discharge.  He  had  gonorrhoea,  again  complicated  by  gonorrhceal 
rheumatism,  and  the  girl  had  a  pretty  sharp  attack  of  gonorrhoea. 

A  gentleman  had  connection  with  a  young  person  whom  he  had  long 
known,  and  whom  he  had  excellent  reasons  for  believing  above  suspicion. 
It  was  followed  by  a  discharge,  which  a  noted  specialist  considered  to  be 
gonorrhoea.  The  surgeon  examined  the  girl,  and  stated  that  there  wa8 
nothing  beyond  slight  leucorrhceal  gleet,  scarcely  more  than  the  natural 
mucus;  in  fact,  he  more  than  hinted  that  she  could  not  have  given  the  dis- 
ease. Three  times  did  this  patient  renew  his  intercourse  with  the  girl, 
each  time  getting  previously  cured  of  his  old  discharge,  and  each  time  get- 
ting a  new  one.  The  surgeon  still  persisted  in  asserting  that  the  girl  had 
nothing  but  a  little  redness  of  the  upper  part  of  the  vagina  with  some 
glairy  mucus  ;  however,  with  the  view  of  making  all  safe,  he  cauterized  her 
thoroughly.  Soon  after  this  she  married,  and  within  a  few  days  her  hus- 
band began  to  show  unequivocal  signs  of  gonorrhoea,  from  which  he  suf- 
fered long  and  severely.  His  wife  had,  as  before,  little  the  matter  with 
her.  I  now  learned  that,  three  years  previous  to  all  this,  she  had  been 
infected  with  gonorrhosa,  but  that  she  had,  as  she  believed,  got  thoroughly 
well  and  remained  so.  I  had  good  reason  to  believe  that  neither  of  these 
two  men  had  ever  had  gonorrhoea. 

Judging,  then,  from  this  and  similar  cases,  I  am  disposed  to  believe 
that  even  a  slight  amount  of  gonorrhoea  is  more  likely  to  excite  the  same  dis- 
ease in  another  person,  than  a  pretty  high  degree  of  leucorrhcea  is  to  bring  on 
even  simple  urethritis. 

Gosselin  thinks  that  in  many  of  these  cases  the  real  secret  is  that  the 
female  has  not  been  examined  at  the  proper  time,  six  or  eight  hours  after 
she  has  made  water,  as  on  waking  in  the  morning  for  instance  ;  and  Dr. 


PATHOLOGY.  .       21 

Howard  throws  further  light  on  this  point  by  maintaining  '  that  the  dis- 
ea,se  will  linger  in  the  small  glands  of  the  female  urethra,  first  described 
by  Dr.  Skene  of  Brooklyn,  and  that  these  will  continue  to  pour  out  true 
gonorrhoeal  pus  although  the  patient  presents  no  other  evidence  of  the  dis- 
ease, a  view  corroborated,  he  considers,  by  the  fact  that  in  a  woman,  who 
thus  infected  her  husband,  applying  carbolic  acid  crystals  to  these  glands 
put  an  end  to  the  communication  of  the  gonorrhoea. 

Ulceration  of  the  neck  or  mouth  of  the  womb,  even  accompanied  by  the 
formation  of  a  stringy  plug  of  mucus,  occurring  in  a  woman  who  has  never 
been  infected,  I  should  be  inclined  to  set  down  as  incapable  of  exciting 
gonorrhoea  ;  the  case  assumes  a  very  different  aspect  when  she  has  been 
exposed  to  the  risk  of  disease,  and  I  have  never  myself  seen  this  state  in 
the  female  under  other  conditions.  In  the  careful  examinations  made  at 
the  Lock  Hospital,  it  is  found  that  women,  having  no  outward  discharge, 
and  yet  infecting  men,  are  seldom  without  this  morbid  secretion  from  the 
os  uteri  or  ulceration  of  the  os  or  cervix.2  If  it  could  be  shown  once  that 
such  an  affection  had  sprung  up  in  a  woman  prior  to  her  having  any  sexual 
congress,  and  then  given  a  discharge  to  another  'person,  the  non-specific 
character  of  gonorrhoea  would  receive  most  strong  support ;  but  I  suppose 
most  persons  familiar  with  hospital  practice  of  this  class  agree  in  the  belief 
that  this  affection,  which  I  look  upon  as  pathologically  distinct  from  the 
secretion  of  mucus  that  in  the  normal  state  plugs  the  canal  of  the  cervix 
.uteri  during  pregnancy  and  the  intervals  between  menstruation,3  is  in 
nearly  every  case  the  sequel  of  gonorrhoeal  vaginitis  ;  which  means  in 
other  words,  that  women  of  this  kind,  without  any  visible  discharge,  give 
gonorrhoea,  not  because  some  natural  secretion  is  in  them  in  a  morbid 
state,  but  because  they  have  had  gonorrhoea.  Dr.  Tyler  Smith  gives  an 
admirable  description  of  the  secretion  sometimes  seen  in  leucorrhcea,  which 
might  easily  be  confounded  with  the  foregoing,  but  which  yet  seems  to  be 
quite  distinct.  It  has  been  stated  that  the  plug  has  been  found  in  some 
instances  to  contain  "  neither  pus-corpuscula  nor  granule  cells,"  but  I  as- 
sume that  it  is  then  incapable  of  conveying  infection.  We  could  scarcely, 
however,  expect  to  find  pus  corpuscles  in  cases  of  leucorrhcea  when  the 
secretion  consists  of  mucus,  and  where  the  white  color  is  due,  not  to  the 
presence  of  inflammation,  but  to'  the  action  of  the  vaginal  acid  on  the 
mucus.  Under  the  head  of  ulceration  are  included  here  cases  of  conges- 
tion with  detachment  of  the  epithelium. 

Purulent  discharge  from  the  interior  of  the  womb,  or,  to  speak  more  cor- 
rectly, from  the  interior  of  the  canal  of  the  cervix,  innocently  acquired, 
sometimes  wears  such  a  serious  look,  especially  if  accompanied  by  vaginal 
discharge,  that  we  might  suspect  it  to  be  an  agent  of  disease,  and  I  have 


1  Chicago  Medical  Review.     Quoted  in  London  Medical  Review,  p.  329.     1882. 

4  Medical  Times  and  Gazette,  vol.  i.,  p.  9.     1868. 

3  Pathology  and  Treatment  of  Leucorrhcea,  p.  36.     By  W.  Tyler  Smith.     1854 


22  ON    GONORRHOEA. 

been  consulted  in  one  or  two  cases  where  a  slight  puriform  running  had, 
judging  from  the  evidence,  been  set  up  in  this  way  ;  but  I  have  not  yet  mtet 
with  an  instance  of  anything,  thus  generated,  which  could  be  set  down 
as  gonorrhoea,  and  indeed  I  have  seen  but  little  of  the  affection.  "Where 
there  has  been  previous  disease,  a  certain  amount  of  infection  may  re- 
main and  become  a  source  of  mischief.  I  have  not  noticed  any  full  obser- 
vations on  this  affection  individually.  Mr.  Berkeley  Hill  says,1  that  a 
purulent  discharge  from  the  uterus  is  an  almost  universal  condition  among 
prostitutes,  but  I  apprehend  that  he  refers  rather  to  the  complaint  de- 
scribed in  the  foregoing  paragraph. 

There  is  reason  to  believe  that  connection  during  or  directly  after  men- 
struation produces  purulent  discharge  in  the  male  sometimes  of  rather  a 
severe  character.  I  have  met  with  a  few  cases  where,  though  disposed  to 
be  skeptical,  I  could  -not  shut  my  eyes  to  the  fact  that  such  might  have 
been  the  case.  There  is,  however,  always  this  difficulty  in  the  back- 
ground when  the  female  is  of  loose  character ;  a  person  in  such  a  posi- 
tion may  have  an  uncured  gleet  hanging  about  her,  and  a  woman  who 
would  not  be  sufficiently  particular  on  the  one  point,  is  just  the  most 
likely  person  to  be  negligent  on  the  other.  Women  with  a  strong  sense 
of  self-respect  do  not  usually  allow  such  approaches.  Any  one  might,  of 
course,  be  surprised  into  such  a  mistake  once,  especially  when  young  and 
newly  married  ;  and  it  is  possible,  from  the  fact  of  menstruation  being 
often  succeeded  by  leucorrhcea  for  a  longer  or  shorter  time,  that  the  close* 
of  the  monthly  discharge  leaves  the  organs  in  a  state  closely  akin  to  that 
of  the  first  stage  of  gonorrhoea.  In  some  forms  of  dysmenorrhcea  an  at- 
tack of  vaginitis  complicates  every  catamenial  period.  But  I  am  led  to 
rate  the  infecting  power  low.  I  have  been  applied  to  four  or  five  times 
by  men  who  had  been  alarmed  by  finding  that  they  had  had  connection 
with  their  wives  at  too  early  a  period  after  menstruation,  so  as  to  cause  a 
return  of  the  discharge,  and  even  when  it  had  come  on  again  during  con- 
gress ;  but  beyond  the  feeling  of  uneasiness  and  irritation,  I  never  knew 
any  ill  results  follow.  In  one  of  these  there  was  ample  reason  for  know- 
ing that  the  patient  was  liable  enough  to  infection  in  the  other  way,  seeing 
that  I  had  attended  him  for  a  most  severe  gonorrhoea,  ending  iu  obstinate 
gleet,  which  had  lasted  between  six  and  seven  years  when  he  came  under 
my  hands. 

In  none  of  the  few  cases  where  I  have  had  to  treat  discharge  from  the 
male  urethra,  stated  by  the  patient  to  have  arisen  from  intercourse  at  the 
menstrual  period,  was  it  complicated  with  orchitis  or  irritable  bladder, 
and  in  one  only  was  chordee  present,  and  then  in  a  very  mild  form. 
Neither  have  I  met  with  an  instance  where,  either  through  accident  or 
imprudence,  the  contagious  nature  of  the  discharge  thus  called  forth  was 
established  by  the  fact  of  its  being  conveyed  to  a  third  person.  Mr.  de 

1  Op.  citat.,  p.  376. 


PATHOLOGY.  23 

Meric,  however,  in  his  answers  to  some  questions  on  this  head,  following 
upon  a  paper  read  by  him  before  the  Harveian  Society,  distinctly,  as  I  un- 
derstood him,  stated  that  the  conveyance  of  infection  under  these  circum- 
stances had  been  noticed. 

We  now  come  to  the  most  singular  cause  of  all,  that  of  a  perfectly 
healthy  state  of  the  organs  in  the  female.  I  wish  to  avoid  tiring  my  read- 
ers with  more  references  than  I  can  help,  and  therefore  confine  myself 
mainly  to  the  statements  of  M.  Kicord,  who  asserts  the  fact  in  the  most 
unequivocal  manner.  What  is  equally  extraordinary,  he  tells  us '  that  a 
man  acclimatized  to  his  wife  has  connection  with  her  and  escapes,  while  the 
lover  who  follows,  not  being  acclimatized,  pays  the  penalty  of  his  indiscre- 
tion. Mr.  Henry  Lee  reproduces3  this  view,  but  rather  as  emanating 
from  M.  Bicord  than  as  according  with  his  own  experience.  Some  other 
eminent  writers  seem  to  have  adopted  it  unreservedly ;  and  M.  Fournier 
improves  so  far  on  M.  Ricord's  view  as  to  maintain,  that  more  frequently 
than  otherwise  a  woman,  who  gives  gonorrhcea,  has  not  got  it ;  while  M. 
Linas  asserted3  before  a  medical  society  that  "history  teaches  us"  that 
gonorrhoea  may  be  given  by  the  most  chaste  of  wives. 

That  gonorrhoea  may  arise  without  any  outward  signs  of  disease  in  the 
female  we  have  just  seen,  but  I  understand  M.  Ricord  to  go  far  beyond 
the  cases  I  have  spoken  of.  His  theory  is,  that  a  woman  who  has  been 
examined  with  the  speculum  and  found  to  be  perfectly  free  from  disease, 
either  of  the  outward  parts  or  of  the  womb,  will  yet  give  gonorrhcea,  al- 
though she  has  never  had  it,  to  a  man  who  has  got  neither  gleet  nor  a  dis- 
position to  it.  Either  he  means  this,  or  he  means  nothing  beyond  what  is 
generally  known.  I  must  leave  it  to  others  to  affirm  or  controvert  a  tenet 
which  is  in  flat  contradiction  with  my  experience,  while  I  pass  on  to  the 
discussion  of  one  which  seems  equally  in  contradiction  with  general  expe- 
rience, and  that  is  the  escape  of  the  husband.  How  comes  it  that  he  gets 
off?  He  was  not  always  acclimatized,  and  ought,  on  M.  Ricord's  own 
showing,  to  have  one  time  or  other  shared  the  lover's  fate.  I  am  therefore 
afraid  that  the  theory  of  acclimatization,  as  M.  Ricord  calls  it,  and  which 
may  remind  some  of  my  readers  of  the  old  belief  that  husband  and  wife 
often  grow  to  be  like  each  other  in  features,  will  hardly  help  us  here.  Even 
those  who  so  unreservedly  accept  M.  Ricord's  version,  must  admit  that  it 
is  hardly  suited  to  England,  where  thousands  of  virtuous  girls  marry  every 
year,  with  their  organs  in  the  state  described  by  him,  and  yet  do  not  com- 
municate gonorrhcea. 

M.  Diday  does  not  go  quite  so  far  as  his  illustrious  teacher ;  he  tells 
us 4  that  any  woman  may  give  gonorrhcea,  and  that  he  makes  no  excep- 

1  Lettres  sur  la  Syphilis,  p.  48. 

2  Holmes's  System  of  Surgery,  second  edition,  vol.  v.,  p.  187. 
9  Union  Medicale,  tome  i. ,  p.  102.     1868. 

4  Exposition  critique,  p.  515.     1858. 


24  ON    GONOREHCEA. 

tions.  Let  her  be  ever  so  healthy  at  the  time  of  her  first  liaison,  she  may 
be  potentially  fit  to  do  any  amount  of  mischief  in  this  way,  and  carry  with- 
in her  a  predisposition  to  communicate  the  infectious  property  to  any  dis- 
charge she  may  acquire,  however  innocently.  The  list  of  affections  which 
may  thus  become  tainted  is  appalling,  but  still  the  vehicle  is  visible,  and 
we  understand  that  such  a  thing,  however  improbable,  might  happen.  M. 
Ricord's  account  is  simply  incomprehensible.  But  this  is  all  the  merit 
that  can  be  conceded  to  M.  Diday's  statement.  It  is  put  forth  in  a  form 
which  robs  it  of  half  its  value.  True,  the  picture  is  graphically  drawn,  in- 
deed, he  yields  here  in  no  way  to  M.  Ricord,  or  perhaps  anyone  else  ;  the 
terms  are  trenchant  and  incisive  enough,  and  the  facts  arrayed  in  a  way 
which  does  credit  to  his  skill  as  a  writer  ;  but  after  all,  it  simply  expresses 
a  conviction  which  may  be  very  well  founded,  but  which  may  equally,  as 
regards  the  evidence  offered,  be  a  truism  or  an  error.  Had  he  told  us 
that  out  of  every  hundred  women  who  marry  so  many  have  a  morbid  dis- 
charge, and  that  out  of  every  hundred  women  who  become  liable  to  such 
discharges  so  many  communicate  gonorrhoea,  we  should  know  what  to  say. 
As  it  is,  his  account  is  more  alarming  than  valuable.  Let  me,  however, 
render  one  tribute  of  justice  to  both  these  charming  writers.  If  they  do 
not  untie  the  knot  they  promote  the  interests  of  morality,  for  it  is  over 
the  head  of  the  erring  lover,  not  the  husband,  that  they  hang  the  impend- 
ing sword. 

3.  The  third  class  of  causes  need  not  detain  us  long.  Those  who 
have  seen  true  gonorrhoea  brought  on  by  eating  asparagus  or  over-fatigue 
have  been  more  favored  than  myself.  I  have  noticed  yellow  purulent  dis- 
charge from  the  urethra  in  an  elderly  man  who,  I  have  very  good  reason 
to  think,  was  strictly  continent ;  and  I  have  seen  a  thin,  yellowish,  dirty> 
and  rather  profuse  discharge  come  on  in  a  young  patient  suffering  from 
bad  influenza.  Such  discharges,  too,  come  occasionally,  but  rarely,  before 
us,  reported  by  the  patient  to  be  the  effect  of  a  sprain.  Again,  I  suppose 
most  practitioners  have  now  and  then  been  consulted  about  a  thick,  white 
secretion  and  scalding,  occurring  in  gouty  persons,  especially  if  the  urine 
should  happen  to  be  loaded  with  urates  and  uric  acid.  As  to  M.  Four- 
nier's  statement,  that  venereal  excess  is  the  most  frequent  cause  of  gon- 
orrhoea, I  meet  it  by  saying  that  I  have  repeatedly  had  to  deal  with  men 
of  unbridled  passions,  who  indulged  such  passions  to  any  extent  with  im- 
punity, never,  indeed,  had  a  sign  of  such  an  affection  so  long  as  they  kept 
aloof  from  prostitutes,  and  whom  I  have  treated  over  and  over  again  for 
gonorrhoea  contracted  in  the  natural  way.  Respecting  all  the  other  agen- 
cies I  have  no  experience,  except  as  to  two  or  three,  and  these  in  a  nega- 
tive sense.  These  remainders,  then,  are  passing  a  bougie,  masturbation, 
scrofula,'  dentition,  piles,  and  ascarides.  The  influence  of  the  first  I 


1  Johnson:  Op.  citat.,  p.  39. 


PATHOLOGY.  25 

should  be  inclined  to  deny,  unless  the  patient  was  suffering  from  gleet  or 
a  tendency  to  urethra!  discharge  set  up  by  stricture.  I  have  passed  the 
bougie  hundreds  of  times  for  spermatorrhoea,  and  never  saw  anything  of 
the  kind  ;  on  similar  evidence  I  question  the  power  of  masturbation, 
though  I  have  recorded  a  case  where  free  purulent  discharge  used  to 
come  on  in  a  young  man  suffering  from  spermatorrhoea.  In  one  elderly 
gentleman,  who  had  never  been  affected  in  any  way,  passing  a  bougie  only 
gently,  even  though  it  had  been  done  several  times  previously  without  any 
such  result,  was  followed  by  slight  discharge  with  a  good  deal  of  excite- 
ment of  urethra  and  bladder,  and  later  on  very  slight  orchitis  ;  symptoms 
apparently  as  much  due  to  excessive  fatigue  and  thundery  weather  as  to 
the  instrument.  Microscopic  examination  showed  considerable  prepon- 
derance of  mucus  ;  discharge  had  almost  entirely  subsided  spontaneously 
in  fourteen  days,  having  been  pretty  clearly  prolonged  by  the  fatigue  and 
thunder.  Of  piles  and  scrofula  I  have  seen  a  pretty  round  number  of 
cases ;  in  not  one  of  them  was  there  ever  a  discharge  innocently  acquired. 
Of  ascarides  I  have  not  had  so  many  cases  under  my  care,  except  in  chil- 
dren ;  in  adults  I  have  not  found  anything  like  urethritis  from  such  a  cause, 
and  the  question  of  dentition  I  consider  to  have  no  bearing  on  the  point. 

But  granting  that  urethritis  is  now  and  then  evoked  by  such  factors, 
it  is,  under  these  circumstances,  as  remote  from  true  gonorrhoea  as  ordi- 
nary conjunctivitis  is  from  purulent  ophthalmia.  It  is  usually  of  so  mild 
and  transient  a  nature,  that  in  no  instance  where  I  have  met  with  it,  has  it 
required  a  remedy  of  any  kind.  Dr.  Francis  Cruize  long  ago  pointed 
out '  a  clear  practical  distinction  between  discharges  produced  by  gonor- 
rhoeal  matter,  and  those  induced  by  non-specific  causes.  While  the  former 
tend  to  run  into  obstinate  gleet,  the  latter  pass  away  spontaneously.  I 
believe  this  rule  holds  good  as  to  the  agencies  included  in  the  third  class 
of  causes  ;  with  regard  to  some  of  those  in  the  second,  especially  menstru- 
ation, it  is  possible  that  there  may  now  and  then  be  an  exception  to  the 
rule. 

Mr.  T.  W.  Nunn  calls  attention  to  another  distinctive  mark.  In  a  com- 
munication to  Dr.  Tyler  Smith,  published  by  the  latter  in  his  work  on 
leucorrhcea,  detailing  a  case  in  which  this  disease  caused  repeated  attacks 
of  balanitis,  he  says  he  is  inclined  to  believe  that  when  urethritis  is  pro- 
duced in  this  manner,  it  makes  its  appearance  immediately  after  connec- 
tion, that  is  to  say,  within  twelve  or  fourteen  hours  ;  whereas  the  urethritis 
produced  by  a  specific  animal  poison  has  a  period  of  incubation  of  from 
four  to  fourteen  days. 

As  to  the  suppression  of  any  skin  disease  being  ever  the  cause  of  gon- 
orrhoea, I  must  go  still  further  and  say,  not  only  that  I  have  never  seen  it, 
but  that  I  can  scarcely  conceive  it  possible.  I  have  made  hundreds,  I 

1  Dublin  Quarterly  Journal,  vol.  xxxix. ,  p.  342. 


26  ON    GONORRHOEA. 

may  safely  say  thousands,  of  attempts  to  check  cutaneous  eruptions,  es- 
pecially eczema,  and  never  yet  saw  any  disturbance  of  the  health  follow. 
Between  the  16th  of  May,  1863,  and  the  18th  of  the  same  month,  1873,  I 
treated  at  Si  John's  Hospital  alone  2,148  cases  of  eczema  on  this  princi- 
ple, with  results  which  justify  me  in  asserting,  what  I  believe  I  was  the 
first  English  author  to  assert,  namely,  that  we  cannot  suppress  eczematous 
or  any  cutaneous  discharge  at  will ;  that,  if  we  succeed  in  time,  arrest 
never  produces  any  injurious  results  ;  and  finally,  that  we  only  succeed  by 
the  use  of  means  which  improve  the  health,  and  I  cannot  conceive  that  the 
use  of  such  means  can  bring  on  gonorrhoea.  However,  as  the  possibility 
of  gonorrhoea  arising  from  this  cause  is  admitted  in  a  pathological  work  of 
high  standing,  a  work  where  every  line  seems  to  have  been  weighed,  and. 
which  might  be  fitly  spoken  of  as  "  finished  with  illustrious  toil,"  I  assume 
that  such  an  occurrence  has  been  noticed. 

Taken  as  a  whole,  I  imagine  that  the  creed  does  not  gain  many  prose- 
lytes at  the  present  day.  Now  that  M.  Kicord's  precepts  no  longer  carry 
the  weight  they  once  did,  now  that  they  are  no  longer  promulgated  by 
some  of  his  disciples  as  if  not  to  accept  them  were  gross,  prejudiced  igno- 
rance, to  doubt  them,  blasphemy,  I  am  inclined  to  think  that  the  old  belief, 
that  gonorrhoea  is  derived  only  from  gonorrhoea,  will  little  by  little  assert 
its  supremacy.  It  is  scarcely  to  be  expected  that  those  who  have  all  along 
taught  the  contrary  will  renounce  views  which  they  have  so  sedulously 
inculcated  for  so  many  years,  and  which  are,  no  doubt,  founded  on  honest 
convictions,  but  we  may  fairly  anticipate  that  with  the  lapse  of  time,  any 
such  opinions  will  vanish  as  completely  into  nothingness  as  a  belief  in  the 
non-specific  nature  of  syphilis  ;  both  of  them  being  specimens  of  the  "  ex- 
traneous idols  "  described  by  Bacon,  which,  "  begotten  of  the  dogmas  and 
schools  of  philosophers  worm  their  way  into  the  minds  of  men,"  and  are 
therefore  fitly  ranked  by  him  as  impediments  to  learning. 

B.  Tn  the  Female. — 1.  Judging  solely  from  what  I  have  been  able  to 
observe,  I  should  say  that  true  gonorrhoea,  capable,  as  a  rule,  of  infecting 
the  male,  is  always  in  the  other  sex,  even  when  only  assuming  the  form  of 
vaginitis  or  vulvitis,  the  result  of  the  contact  of  matter  derived  from  a  per- 
son suffering  under  gonorrhoea,  generally,  of  course,  communicated  by 
sexual  intercourse.  Dr.  Gaillard  Thomas  takes  '  the  same  view  of  the  case  : 
he  considers  that  gonorrhoea  in  the  female  altogether  arises  from  a  specific 
contagion.  In  newly  married  women  a  good  deal  of  purulent  inflammation, 
pain  and  swelling  of  the  vulva,  redness  and  heat  of  the  vagina,  ardor  urinae, 
and  uneasiness  in  sitting  or  riding  on  horseback,  may  make  their  appear- 
ance, and  in  some  cases  excite  suspicion  that  gonorrhoea  has  been  commu- 
nicated. But  the  course  of  the  disorder  soon  reveals  the  difference,  for 
though  in  a  few  rare  cases  the  symptoms  rise  to  such  a  height  as  to  require 

1  Practical  Treatise  on  the  Diseases  of  Women,  p.  154.     1875. 


PATHOLOGY.  27 

medical  attendance,  yet  for  the  most  part  they  pass  off  spontaneously,  or 
at  the  worst  yield  to  any  mild,  simple  treatment ;  whereas  true  gonorrhoea 
is  a  more  severe  and  infinitely  more  obstinate  affection,  generally  demand- 
ing, in  the  long  run,  a  decided  and  sometimes  prolonged  course  of  treat- 
ment. At  the  same  time  I  feel  bound  to  admit  that  this  view  is  in  direct 
opposition  to  that  held  by  some  writers.  Dr.  Bumstead,  for  instance,  says 
he  has  had  reason  to  believe  that  the  frequent  repetition  of  the  sexual  act 
has  produced  gonorrhoea  in  women  free  from  any  previous  disease.  Again, 
an  affection  due  solely  to  repeated  and  unwonted  intercourse  rarely  extends 
to  the  urethra,  bladder,  womb,  and  ovaries,  as  sometimes  happens  with 
genuine  gonorrhoea.  I  know  cases  are  cited  in  which  such  symptoms  were 
found,  and  where  the  husband  most  strenuously  denied  having  had  any 
infection  at  the  time  of  marriage.  Were  the  denial  always  well-founded, 
the  beh'evers  in  the  non-specific  nature  of  the  disease  would  have  a  strong 
case  here ;  but  it  is  as  certain  as  any  fact  can  be  that  many  men  marry 
without  being  perfectly  cured — some  from  natural  laziness  and  neglect, 
some  because  they  really  believe  they  are  cured,  and  a  third  class  because 
they  must  fulfil  the  engagement  at  a  stated  time,  etc. ;  and  I  have  seen 
cases  which  amply  justify  me  in  thinking  that  this  uncured  state  is  not 
unfrequently  the  cause  of  gonorrhoea  put  down  to  a  more  innocent  origin. 

When,  in  a  female,  the  signs  of  infection  are  seated  in  the  urethra,  the 
specific  nature  of  the  affection  is  admitted  by  those  who  oppose  it  when 
the  affection  shows  itself  in  other  parts,  and  notably  by  M.  Ricord  himself.1 
It  is  therefore  just  as  well  to  bear  in  mind  that,  as  one  form  of  gonorrhoea, 
is  always  due  to  a  specific  cause,  other  forms  may  also  be  due  to  the  opera- 
tion of  the  same  law.  We  know  that  they  often  are  so. 

The  next  question  is,  can  a  man,  who  has  contracted  a  discharge  from  a 
woman  laboring  under  leucorrhcea,  or  simple  vulvitis,  or  who  is  not  quite 
free  from  the  catamenial  flow,  give  another  woman  true  gonorrhoea  ?  My 
reply  must  be  that  I  have  never  been  able  to  satisfy  myself,  in  my  own 
practice  and  observations,  of  such  a  fact,  and  the  reader  will  see  farther  on 
the  reasons  I  have  to  offer  for  exercising  caution  before  a  decision  is 
formed. 

3.  Lastly,  we  have  to  consider  the  possibility  of  transmitting  to  the  fe- 
male a  discharge  set  up  in  the  male  urethra  by  any  of  the  mechanical  or 
other  irritants  spoken  of  in  the  third  class  enumerated  previously.  It  will, 
perhaps,  conduce  both  to  clearness  and  brevity  if  we  take  the  two  last  sets 
of  causes  together. 

In  the  first  place  it  is  to  be  remembered  that  we  must  often  deal  with 
a  very  suspicious  class  of  facts.  Trustworthy  men,  the  men  on  whose 
evidence  we  could  best  rely,  are  the  most  likely,  when  they  find  themselves 
suffering  under  a  discharge  of  this  kind,  to  abstain  from  connection,  and 

1  Lettres  sur  la  Syphilis,  p.  61. 


28  ON    GONORRHCEA. 

•very  properly  too.  Consequently  the  proof  most  wanted  is  the  most  dif- 
ficult to  get. 

Secondly,  we  have  to  separate  facts  which  have  been  confounded  to- 
gether. For  instance,  it  seems  to  be  assumed  by  some  authors,  that  when 
symptoms  run  high,  infecting  power  must  be  present.  But  the  two  ques- 
tions are  quite  distinct.  Severity  is  not  evidence  of  contagious  power. 
Take  the  case  of  Swediaur.  He  gave  himself  as  bad  urethritis  as  a  man 
could  well  have,  by  injecting  ammonia  into  the  canal,  but  as  evidence  of 
such  a  disorder  being  able  to  infect  the  female,  his  experiment  is  worth- 
less. Yet  who  can  doubt  that  some  of  those  who  speak  of  his  case  have 
not  kept  the  line  of  demarcation  so  clearly  in  view  as  they  might  have 
done  ? 

Some  of  the  causes  assigned  may  at  once  be  rejected  ;  they  are  far  too 
improbable  for  any  rational  being.  Thus,  e.g.,  Dr.  Tanner  was  present 
when  a  surgeon  suggested  that  making  water  in  the  night  air  might  bring 
on  gonorrhoea ;  and  Mr.  Johnson  relates '  that  a  patient  wanted  the  stu- 
dents at  St.  George's  Hospital  to  believe  that  in  his  case  gonorrhoea  had 
been  brought  on  by  the  exertion  of  lopping  a  tree  ;  he  having  nothing  the 
matter  with  him  when  he  began  his  task,  and  finding  the  discharge  fully 
developed  when  he  came  down  ! 

A  medical  man  credulous  enough  to  fancy  that  night  air  could  exert 
any  such  influence  would  not  be  likely  to  investigate  facts  with  proper 
care  ;  and  a  patient  who  had  the  effrontery  to  tell  such  a  barefaced  false- 
hood would  be  just  the  person  to  conceal  the  fact  that  he  had  had  inter- 
course with  a  prostitute.  The  possibility  of  late  hours,  too,  having  any 
such  effect  is  one  I  should  be  very  much  inclined  to  question.  It  is,  there- 
fore, only  against  the  more  probable  of  these  causes  that  any  arguments 
are  directed. 

It  must  always  be  kept  in  view  that  many  patients  are  possessed  with  a 
desire  for  finding  any  reason  but  the  right  one.  It  is  not  that  they  wish 
to  deceive  the  surgeon.  Most  probably  it  arises  as  much  as  anything  from 
a  desire  to  extenuate  the  responsibility  of  the  female,  or  to  set  up  a  higher 
standard  for  her  health  and  physique  than  they  are  entitled  to.  Be  that 
as  it  may,  it  is  quite  certain  that  they  will  snatch  at  a  straw  to  save  their 
-drowning  theory,  and  are  only  too  happy  to  find  the  surgeon  concur  with 
them  in  ascribing  the  disease  to  such  innocent  causes  as  a  strain,  a  cold, 
etc.  Still,  making  all  allowance  for  bad  logic,  for  the  morbid  desire  to  im. 
pose  on  medical  men  on  the  one  hand,  or  on  their  own  judgment  on  the 
other,  it  must  be  granted  that  cases  of  discharge  from  such  causes  are  met 
with. 

And  first,  I  have  to  urge  that  a  very  slight  gleet,  a  tender  state  of  the 
urethra  left  behind  by  a  gonorrhoea  suffered  to  die  out  of  itself,  or  only 

1  Op.  citat,  p.  27. 


PATHOLOGY.  29 

treated  with  medicines,  meaning  really  uncured  gleet  ready  to  break  out 
again  at  any  moment,  and  sometimes  even  incipient  gonorrhoea,  are  often 
at  the  bottom,  not  only  of  the  disease  conveyed  to  the  female,  but  of  the 
symptoms  set  up  in  the  male  also.  I  have  been  consulted  in  several  cases 
where  the  urethra  had  remained  free  from  visible  disease  for  a  pretty  long 
period,  owing  apparently  to  the  patient  leading  a  quiet  life,  and  abstaining 
from  connection  ;  and  where  yet  the  disease  soon  ripened  into  dangerous 
activity  under  the  influence  of  sexual  indulgence.  As  to  gonorrhoea  itself,  I 
believe  it  to  be,  both  in  its  decline,  when  there  is  scarcely  a  speck  of  dis- 
charge left,  and  in  its  nascent  stage,  when  the  most  timid  might  think  there 
was  no  ground  for  alarm,  infectious  in  a  very  high  degree  for  some  persons. 

A  lady,  whose  husband  had  brutally  assaulted  her,  left  him  in  conse- 
quence. As  her  womb  was  thought  to  be  injured,  I  carefully  examined 
her,  and  certainly  I  had  every  reason  for  saying  that  she  was  at  this  time 
perfectly  healthy.  Some  time  afterward  she  became  attached  to  a  gentle- 
man who  had  been  very  kind  to  her  in  her  troubles,  and  who  occasionally 
consulted  me  for  a  very  slight  gleet ;  so  slight,  indeed,  that  sometimes  it 
left  no  mark  on  his  shirt,  sometimes  a  pale  one  not  bigger  than  a  sixpence, 
but  never  more  than  this.  This  fluid  was  simply  whitish  mucus.  Had 
the  patient  asked  me  the  question,  I  should  have  said  that  such  a  dis- 
charge, albeit  the  relics  of  a  gonorrhoea  contracted  two  years  previously, 
was  innocuous ;  fortunately,  he  took  this  responsibility  off  my  shoulders. 
The  attachment  was  followed  by  connection,  of  which  I  first  became  aware 
in  consequence  of  the  lady  presenting  herself  in  great  distress,  with  every 
symptom  of  a  violent  gonorrhoea,  from  which  she  suffered  very  severely. 
Of  course,  the  infection  might  have  been  derived  from  another  source  ; 
but  knowing  her  family  intimately  as  I  did,  having  always  heard,  even  from 
her  husband,  that  her  character  was  up  to  this  time  irreproachable,  and 
that  her  disposition  was  averse  to  anything  like  sensuality  or  impropriety, 
I  think  it  may  be  inferred  that  she  caught  the  gonorrhoea  from  my  pa- 
tient. 

When,  however,  there  are  no  pus-corpuscles  in  the  discharge,  there  is 
most  probably  no  danger.  I  need  scarcely  say  that  it  is  not  very  easy — 
perhaps  it  is  impossible,  to  prove  such  a  point,  especially  as  one  source  of 
observation,  the  existence  of  pure  mucous  gleet  in  the  male,  is  not  very 
common.  The  only  evidence  I  have  to  offer  is  simply  that  I  have  never 
been  able  to  find,  either  in  the  practice  of  others  or  in  my  own,  a  single 
complete  history  of  a  case  of  gonorrhoea  being  communicated  to  the  female, 
unless  there  was  positive  proof  of,  or  very  strong  reason  to  suspect,  the  ex- 
istence of  a  certain  amount  of  pus  in  the  discharge  by  which  she  was  in- 
fected. Dr.  Durkee  says,1  that  if  there  be  no  pus-cells  in  the  discharge, 
there  is  no  danger  of  infection,  and  the  reader  will  see  that  I  agree  with 

1  Op  citat ,  p.  29. 


30  ON    GONORRH(EA. 

him.  The  requisite  amount,  however,  seems  in  some  cases  to  be  very 
small. 

Mr.  R consulted  me  about  the  middle  of  December,  1873.  His  ac- 
count was,  that  owing  to  protracted  absences  from  home,  and  the  disincli- 
nation his  wife  had  long  shown  for  sexual  intercourse,  he  had  remained 
almost  always  continent  for  the  last  five  years  ;  that,  three  days  previously, 
he  had  in  the  evening  a  suspicious  connection,  which  was  followed,  two 
nights  later,  by  intercourse  with  his  wife  ;  and  that  he  had  been  alarmed 
by  noticing,  the  morning  after,  that  is  to  say  the  morning  of  his  visit  to  me, 
a  slight  discharge,  which  he  distinctly  stated  had  not  shown  itself  before. 
On  examining,  I  found  the  lips  of  the  urethra  wet  with  a  sticky  secretion, 
which  looked  more  like  thick  serum  than  mucus  ;  there  did  not  appear  to 
be  any  pus  in  it.  Within  a  few  days  his  wife  began  to  complain  of  uneasi- 
ness in  the  private  parts.  I  examined  her,  and  found  considerable  dis- 
charge from  the  vagina ;  there  was  also  some  swelling  with  tenderness  in 
the  right  groin.  The  next  day,  the  discharge  being  thoroughly  washed 
off,  I  cauterized  the  vagina  pretty  freely,  and  two  days  after  repeated  the 
process.  The  affection,  whatever  it  might  have  been,  yielded  to  this  treat- 
ment, which  was  seconded  by  the  use  of  aperients,  preparations  of  potass, 
rest,  and  low  diet.  In  the  husband  the  symptoms  developed  into  distinct 
purulent  running.  I  may  add  that  this  lady  was  not  in  any  way  subject 
to  leucorrhcea,  having  had  no  symptom  of  the  kind.  The  urethra  was  not 
implicated  in  her  case. 

Contrast  this  with  the  f ollowing  case,  in  which  there  was  as  great  a  de- 
gree of  incipient  inflammation  from  a  mechanical  irritant.  A  gentleman, 
who  had  suffered  severely  from  spermatorrhoea,  married.  Finding  that 
connection  only  made  him  worse,  he  came  up  to  London,  and  placed  him- 
self under  my  care.  I  found  the  tendency  to  emissions  as  strong  as  ever, 
the  urethra  excessively  tender,  red,  and  secreting  mucus  freely.  On 
placing  a  little  of  this  under  the  microscope,  it  was  seen  to  be  swarming 
with  inflammation  corpuscles  (cells).  There  was,  however,  no  pus,  nor 
had  there  been  any,  and  there  was  no  history  of  gonorrhoea.  This  condi- 
tion seemed  to  have  been  brought  on  by  masturbation,  followed  by  exces- 
sive connection.  As  he  had  got  the  fancy  into  his  head  that  he  must  have 
given  his  wife  the  same  disease  as  himself,  I  examined  her  at  his  request. 
The  most  careful  search  with  the  speculum  revealed  only  a  perfectly 
healthy  state.  Some  time  after  he  again  consulted  me,  and  stated  that  she 
had  remained  quite  well 

It  does  not,  however,  follow  from  what  has  just  been  said,  that  every 
slight  gonorrhoeal  discharge,  in  its  first  or  its  last  stage,  must  necessarily 
convey  infection.  Just  as  there  are  some  men  so  constituted  that  they  are 
almost  certain  to  catch  gonorrhoea  nearly  every  time  they  commit  an  im- 
prudence, while  other  men  repeatedly  court  risk  and  yet  escape  again  and 
again,  or  if  they  do  in  the  long  run,  as  perhaps  always  happens,  become 


PATHOLOGY.  31 

infected,  the  gonorrhoea  dies  out  of  itself,  or  yields  to  such  simple  reme- 
dies as  a  few  injections  of  cold  water ;  failing,  however  often  the  attack 
may  be  repeated,  to  bring  on  any  of  the  more  severe  results,  or  to  entail 
more  than  some  slight  inconvenience,  so  does  the  susceptibility  vary  in 
women.  Some  will  suffer  most  severely  and  for  a  long  time  where  others 
would  probably  get  off  safe  ;  or  again,  a  woman  may  here  and  there  be 
found  so  constituted  as  to  expose  herself  with  impunity  to  contagion  in  its 
worst  form.  I  have  known  instances  where  men,  with  some  amount  of 
gonorrhceal  discharge  still  remaining,  had  not  communicated  any  disease 
to  young  women,  whom  one  might  have  thought  susceptible  enough  ;  I 
am  speaking,  too,  of  cases  where  the  argument  about  frequency  of  inter- 
course having  something  to  do  with  the  power  of  resisting  infection  could 
not  be  urged  ;  and  M.  Robert  says  that  women  having  connection  with 
men  in  the  first  stage  of  blennorrhagia,  constantly  avoid  infection.  But 
supposing  that  we  can  look  upon  both  these  positions  as  established,  they 
are  only  rare  instances  of  a  disparity  in  receptive  power  which  extends 
itself  to  all  diseases  and  both  sexes. 

The  reader  has  most  likely  pretty  well  anticipated  what  I  have  to  say 
about  the  probability  of  urethritis,  brought  on  in  the  male  by  any  of  the 
irritants  mentioned  in  the  third  class  being  conveyed  to  the  female.  I 
have  already  given  my  reasons  for  saying  that  the  disorder  is  mild,  and 
that  the  cases  are  fewer  than  are  sometimes  supposed  ;  that  it  is  really 
quite  an  occasional  event  when  running  is  set  up  by  such  causes  as  cold, 
gout,  strains,  etc.  Still,  as  they  are  met  with,  we  have  to  investigate  the 
fact  of  their  transmission.  Now  though  I  have  once  or  twice  known  men 
so  infected  have  connection,  not  only  with  their  wives,  but  with  other 
women,  I  have  never  seen  any  discharge  whatever  thus  brought  on  in  the 
female  ;  or  rather,  I  ought  to  say  that  the  answers  to  my  questions  have 
been  in  the  negative,  for  I  never  had  an  opportunity  of  hearing  the  evi- 
dence on  the  other  side.  At  the  same  time  I  ought  to  add  that  my  ex- 
perience here  has  been  small,  although  I  have  seen  so  many  cases  of 
gonorrhoea. 

It  is  quite  certain  that  some  of  those  women  who  have  suffered  from 
gonorrhoea  and  discharge  produced  by  other  causes  than  connection,  draw 
a  broad  and  practical  distinction  between  the  two.  Among  other  cases  I 
may  state  the  following  : 

A  lady  was  infected  with  gonorrhoea  by  her  husband.  After  being 
under  the  care  of  two  surgeons,  one  of  whom  practised  chiefly  in  this 
special  branch,  she  consulted  me.  I  had  great  difficulty  in  curing  her,  and 
only  succeeded  by  means  of  repeated  blistering  and  cauterizing  the  vagina 
and  mouth  of  the  womb  freely.  She  now  separated  from  her  husband. 
A  considerable  time  after  this  she  married  again,  and  again  contracted 
gonorrhoea,  which  also  required  a  considerable  time  to  remove.  Seven 
years  subsequently  she  consulted  me  for  a  muco-purulent  discharge  from 


i32  ON    GONOKRHCEA. 

the  vagina.  Knowing  how  severely  she  had  suffered  on  the  two  former 
occasions,  I  gave  a  guarded  opinion  as  to  the  time  it  would  require  for  a 
cure,  but,  to  my  surprise,  she  avowed  her  conviction  that  she  would  soon 
be  well,  as  the  discharge  had  not  arisen  from  connection,  and  as  she  had 
three  years  before  suffered  from  a  similar,  but  a  more  severe  attack,  after 
long  exposure  to  great  cold  when  travelling,  which,  though  accompanied 
by  considerable  pain  and  even  the  formation  of  abscess,  got  quite  well  in  a 
few  weeks,  with  very  simple  treatment.  It  was  a  very  different  affair  for 
all  that,  she  said,  from  either  gonorrhoea.  The  result  in  the  present  case 
proved  that  she  was  right,  as  she  was  well  in  ten  days,  though  she  only 
took  some  saline  and  merely  used  a  lead  lotion. 

Against  this  we  have  to  set  the  experience  of  Dr.  A.  Hiller,  who,  it 
seems,1  inoculated  his  own  wife  with  the  muco-purulent  secretion  brought 
on  in  the  urethra  by  a  mechanical  irritant,  and  succeeded  in  reproducing 
the  discharge.  I  have  not  seen  his  pamphlet,  and  trust  entirely  to  the 
abstract  of  it  in  the  German  "  Archives  of  Dermatology,"  which  does  not 
contain  any  account  of  the  experiment.  Without  contesting  the  accuracy 
of  the  conclusions  drawn  by  Dr.  Hiller,  I  am  yet  forced  to  say  that  an  ex- 
periment, designed  to  succeed,  is  a  very  different  affair  from  the  facts  of 
every-day  life  ;  and  that  it  would  require  not  one,  but  several  trials  to  es- 
tablish the  fact  of  communicability,  and  a  separate  series  to  show  that  the 
disease,  so  generated  in  the  female,  was  identical  with  gonorrhoea.  Inoc- 
ulation is,  no  doubt,  a  valuable  means  of  observation,  but  it  has  more  than 
once  led  to  serious  error. 

Point  at  which  Infection  takes  place  in  the  Male  ;  Seat  of  Gonorrhoea  in 
the  Male. — Infection  most  probably  takes  place  at  the  reflection  of  the 
mucous  membrane  from  the  urethra  over  the  glans  ;  the  lips  of  the  urethra. 
I  imagine  no  fluid  from  the  female  can  possibly  enter  the  urethra  during 
connection,  owing  to  the  turgescence  of  the  penis  completely  closing  the 
passage  ;  and  were  any  introduced,  it  must,  one  would  think,  be  forced  out 
again  when  the  semen  is  expelled.  The  glans  seems  in  no  way  implicated 
in  the  process,  as  gonorrhoea  is  met  with  often  enough  in  Jews  and  others 
who  have  the  glans  uncovered  from  youth  upward,  and  in  whom  the  skin 
covering  it  is  so  dry  as  to  be  apparently  quite  insusceptible  of  infection. 
Moreover,  the  symptoms  at  the  commencement  are,  I  believe,  invariably 
limited  to  the  neighborhood  of  the  lips ;  chordee,  pain  in  the  perineum, 
irritable  bladder,  and  swelled  testicle  never  appear  till  the  inflammatory 
symptoms  near  the  mouth  of  the  urethra  have  lasted  some  little  time. 

I  shall  perhaps  be  told  that  the  presence  of  chancre  in  the  male  urethra 
is  fatal  to  such  a  view,  as  in  this  case  discharge  from  the  female  must  be 
carried  down  the  urethra.  There  is,  no  doubt,  a  good  deal  of  force  in  the 
argument.  I  am  myself  disposed  to  think,  from  the  presence  of  chancre 


1  Archiv.  fur  Dermatologie,  etc.,  B.  4,  S.  555. 


PATHOLOGY.  33 

manifesting  itself  so  generally  within  a  very  limited  range  of  space,  that 
the  chancrous  action  begins  at  the  mouth,  and,  when  it  does  not  expend 
its  force  there,  spreads  in  a  diffused  form,  like  the  gonorrhceal  action  itself, 
till  it  reaches  a  part  of  the  urethra  where,  owing  to  peculiarity  of  tissue  or 
tendency  to  take  on  an  ulcerative  action,  it  can  develop  itself.  My  reason 
for  assuming  that  something  of  this  kind  occurs  is,  that  chancre  has  been 
found  so  low  down  the  urethra  that  it  really  requires  a  stretch  of  the  im- 
agination to  believe  any  fluid  from  the  vagina  could  be  propelled  so  far 
along  a  narrow  and,  at  the  same  time,  swollen  canal ;  especially  consider- 
ing how  strong  the  disposition  is  of  the  urethra  to  extrude  everything  in 
the  shape  of  a  foreign  body,  and  even  its  own  secretions  when  more  co- 
pious than  usual. 

The  seat  of  gonoiThcea  varies  most  materially,  both  according  to  the 
date  after  infection  at  which  the  patient  is  seen  and  the  disposition  of  the 
urethra  to  take  on  the  purulent  action,  a  disposition  which  is  not  always 
alike  in  the  same  individual,  and  which  is  certainly  widely  different  in 
different  persons.  At  the  outset  the  seat  of  the  disease  is,  as  I  have  said, 
limited  to  the  very  vicinity  of  the  mouth  of  the  urethra,  but  after  a  few 
days  have  elapsed  we  find  every  degree  of  severity  as  to  extent.  In  some 
persons  the  inflammation  spreads  rapidly,  in  others  slowly,  backward, 
reaching  in  succession  the  bulb,  membranous,  prostatic  portions  of  the 
urethra,  the  bladder,  and  so  on.  I  tried  hard  for  a  long  time  to  make  out 
if  there  was  any  law  under  the  influence  of  which  this  extension  takes 
place,  but  after  collecting  a  number  of  observations  I  gave  it  up. 

These  views  were  made  public  several  years  ago  at  a  meeting  of  the 
Medical  Society  of  London,  and  again  at  more  length  in  the  third  edition 
of  this  work,  published  in  1871.  Some  years  ago  an  important  paper  on 
the  subject  appeared  from  the  pen  of  M.  Ledeganck.1  This  gentleman, 
who  has  examined  the  urethra  in  the  living  subject  by  means  of  a  cylinder 
of  thin  glass,  says  that  in  the  majority  of  cases  the  disease  begins  in  the 
fossa  navicularis.  Fifteen  or  twenty  hours  after  infection,  he  tells  us,  the 
vessels  of  the  parts  are  injected,  the  seat  of  the  hypersemia  being  strictly 
limited  to  the  frsenum,  and  stopping  almost  at  the  borders  of  the  meatus. 
On  the  second  day  the  injection  has  extended  to  the  interior  of  the  navicu- 
lar  fossa.  When  the  urethra  is  examined  with  the  glass,  it  is  found  that 
the  mucous  membrane  presents  a  port-wine  hue,  which  springs  from  the 
anterior  lip  of  the  meatus  and  extends  down  the  canal  in  the  form  of  two 
or  three  descending  and  diverging  striae.  On  the  third  day  the  port- wine 
hue  has  become  intense,  and  the  part  so  colored  has  the  form  of  a  myrtle- 
leaf,  with  the  base  at  the  anterior  border  of  the  meatus,  and  the  apex  about 
three-quarters  of  an  inch  down  the  passage.  After  the  third  day  the  in- 


1  Journal  de  Medecine,  November,  1871.     Quoted  in  the  Practitioner,  vol.  viii.,  p. 
183. 

3 


34  ON    GONORRHCEA. 

jection  extends  rapidly  toward  the  deeper  parts,  and  its  limits  can  then 
110  longer  be  accurately  fixed.  According  to  Desormeaux  the  disease  has 
by  the  eighth  day  engaged  the  anterior  half  of  the  urethra,  the  mucous 
membrane  being  red,  rough,  and  presenting  the  appearance  of  superficial 
ulceration,  the  exfoliations  of  Fournier,  like  those  sometimes  seen  in  bal- 
anitis.  In  this  case  the  endoscope  is  an  insufficient  guide,  as  I  have  known 
the  prostatic  part  of  the  urethra  and  the  bladder  affected  within  the  first 
week. 

Dr.  Cruize  concludes  that  in  true  gonorrhoea  the  inflammation  spreads 
backward  over  the  whole  length  of  the  canal,  and  then  either  contracts 
the  area  of  its  operation  toward  the  orifice,  or  fastens  upon  the  posterior 
tract  of  the  urethra  from  the  bulbous  to  the  prostatic  part.  When  it  fixes 
itself  near  the  bulb,  which  is  its  seat  of  predilection,  it  brings  on  a  gran- 
ular state  of  the  urethra,  which  has  no  tendency  to  get  well  of  itself.  De- 
sormeaux maintains  that  after  a  time  the  disease  tends  spontaneously  to 
contract  its  area.  The  anterior  part  of  the  canal  may  reassume  a  healthy 
appearance,  and  in  many  persons  the  prostatic  portion  may  recover  its 
normal  state,  while  the  bulb  and  membranous  part  of  the  canal  are  still 
affected.  In  some  rare  instances  the  inflammation  is  limited  to  the  navic- 
ular  fossa. 

Therefis  no  such  thing  as  "  the  specific  seat  of  gonorrhoea."  In  a  dozen 
successive  cases  the  area  and  seat  of  the  disease  may  not  be  alike  in  ajiy 
two.  How  and  when  the  idea  originated  that  the  disease  is  confined  to 
the  first  two  inches  of  the  urethra,  I  have  not  been  able  to  make  out. 
Hunter,  who  has  been  saddled  with  the  responsibility,  never  said  anything 
of  the  kind  ;  he  certainly  looked  upon  it  as  the  part  most  commonly  af- 
fected,1 and  contended  that  the  inflammation  does  not  usually  go  farther 
than  two  or  three  inches  from  the  meatus,2  a  doctrine  taught  by  at  least 
one  surgeon,3  though,  perhaps,  not  very  clearly,  long  before  the  appearance 
of  Hunter's  work  ;  but  he  never  expressed  such  a  view  as  that  the  inflam- 
mation is  always  confined  to  this  part ;  so  far  from  it,  he  distinctly  says  4 
that  "  we  sometimes  find  the  irritation  and  inflammation  exceed  the  spe- 
cific distance  and  spread  through  the  whole  of  the  urethra."  Cockburn,  too, 
in  the  fourth  edition  of  his  work  on  gonorrhoea,  published  in  1728,  if  not 
in  his  earlier  productions,  expresses 6  his  conviction  that  the  inflammation 
extends  to  the  neck  of  the  bladder. 

Again,  Sir  Astley  Cooper  examined  the  body  of  a  man  executed  at  the 
Old  Bailey  while  suffering  under  gonorrhoea,  and  found  that  the  inflamma- 
tion was  greatest  in  the  first  three  inches  of  the  urethra,  but  that  the  lin- 
ing membrane  was  inflamed  up  to  the  membranous  portion.6  The  doc- 

1  Treatise  on  the  Venereal  Disease,  p.  50.     1786.  s  Ibid.,  p.  47. 

3  Venereal  Gonorrhoea,  p.  18.     By  James  Neville.    1754. 

4  Op.  citat.,  p.  51.  5  Page  271. 
8  On  the  Structure  aud  Disease  of  the  Testis,  Part  II.,  p.  15.  1830. 


PATHOLOGY.  35 

trine  of  limitation  to  a  specific  seat  was  also  opposed,  long  ago,  by  an  ex- 
cellent observer,  Dr.  Egan,  who  as  far  back  as  1848  stated  '  that  gonorrhoea 
•sometimes  engages  the  "whole  extent  of  the  urethra,  and  by  Mr.  Colles  in 
1850,  who  maintained "  that  the  inflammation  may  spread  as  far  as  the 
bladder,  and  even  at  times  to  the  ureters  and  kidneys.  He  found  the  urine 
loaded  with  pus  from  the  bladder  in  two  or  three  days  from  the  beginning 
of  the  gonorrhoea. 

Post-mortem  examination  reveals  little  for  or  against  M.  Ledeganck's 
account.  I  have  only  twice  examined  a  gonorrhoeal  urethra  after  sudden 
death.  Both  patients  committed  suicide.  It  was  difficult  to  say  exactly 
where  the  inflammation,  which  was  principally  shown  by  a  punctiform 
reddened  state  of  the  membrane,  really  stopped  ;  but  it  could  not  be  said 
to  extend  beyond  three  and  a  half  inches  in  one  case  and  three  in  the 
other.  Hunter  simply  says  that  in  such  cases  he  found  the  urethra  a  h'ttle 
bloodshot.  Dr.  Stoll,  of  Vienna,  examined  very  carefully  the  urethra  of  a 
man  who  died  in  his  hospital  while  suffering  from  "a  virulent  clap."  He 
found  the  internal  surface  preternaturally  red,  two  of  the  lymphatics  white 
and  enlarged,  and  puriform  matter  oozing  out  from  the  internal  membrane, 
especially  at  the  lacuna.3  Drs.  Jones  and  Sieveking  only  state  that  the 
mucous  lining  becomes  swollen,  injected,  and  covered  with  mucus  or 
muco-purulent  secretion,  the  follicles  and  lacunae  being  attacked,  particu- 
larly the  lacuna  magna.  Dr.  Charteris,  in  his  account 4  of  a  post-mortem 
held  on  a  lad  who  died  in  six  days  of  pyaemia  from  gonorrhoea,  says  "  the 
interior  of  the  anterior  part  of  the  urethra  was  congested,  with  a  small 
longitudinal  thickened  red  patch,  a  quarter  of  an  inch  long,  on  the  floor 
of  the  urethra,  three  inches  from  the  anterior  orifice."  Fournier  gives 
among  the  post-mortem  signs  tumefaction  of  the  mucous  membrane, 
•"  linear  arborization,"  punctiform  injection  of  the  canal,  redness  of  the 
urethral  sinuses,  granulations  developed  at  certain  limited  points  of  the 
passage  and  most  frequently  united  into  groups,  and  exfoliation  of  epithe- 
lium very  much  akin  to  ulceration. 

M.  Bonniere,  who  unequivocally  maintains  the  specific  nature  of  gonor- 
rhoea, examined 5  the  bodies  of  several  soldiers  who  died  of  Asiatic  cholera 
in  1854,  while  suffering  from  gonorrhoea  in  its  most  developed  form.  He 
found  very  slight  traces  of  inflammation  in  the  navicular  fossa  ;  the  sur- 
face was  punctate,  red,  and  robbed  of  its  polish.  In  the  spongy  part  the 
mucous  membrane  was  thickened  but  scarcely  reddened  ;  the  appearances 
in  the  membranous  part  resembled  those  in  the  fossa.  But  everywhere 
he  noticed  that  the  foramina  were  visible,  and  that  the  circumferences  of 
their  orifices  were  of  a  violet  red  and  deprived  of  epithelium. 

1  Dublin  Quarterly  Journal,  vol.  v. ,  p.  404.  *  Ibid. ,  vol.  x. ,  p.  103. 

3Swediaur:  Op.  citat.,  p.  24. 

4  British  Medical  Journal,  vol.  ii.,  p.  712.    1876. 

5  Archives  Generates  de  Medecine,  tome  i.,  p.  405.     1874. 


36  ON    GONOKRHCEA. 

According  to  him  the  parts  capable  of  taking  on  gonorrhceal  action  are 
the  glans,  prepuce,  urethra,  especially  the  navicular  fossa  and  prostatic 
region,  excretory  canal  of  glands  of  Littre,  conjunctiva,  anus,  mouth  vulva, 
vagina,  os  uteri,  lower  portion  of  cervix  uteri  and  the  prostatic  utricle  ;  those 
refractory  to  infection  of  this  nature  are  the  rectum,  lachrymal  canal,  body 
of  uterus,  seminal  vesicles,  vas  deferens,  prostatic  canals,  bladder,  excre- 
tory duct  of  glands  of  Cowper  and  Bartholini.  The  susceptible  parts  are 
carpeted  with  pavement  epithelium,  provided  with  papillae  and  a  superfi- 
cial subepithelial  mesh  of  minute  lymphatic  ducts  ;  the  others  are  paved 
with  cylinder  epithelium,  and  have  a  superficial  vascular  network.  The 
congeries  of  epithelial  capillary  lymphatics  is  not  to  be  confounded  with 
the  mesh  of  lymphatics  described  in  anatomical  treatises  ;  it  is  a  capillary 
network  of  small  vessels,  the  outer  wall  of  which  is  formed  of  pavement 
epithelial  cells.  He  therefore  holds  that  in  gonorrhoea  there  is  a  change 
of  a  virulent  nature  in  the  epithelial  cells  of  the  superficial  lymphatic  sys- 
tem of  the  mucous  membrane,  with  pavement  epithelial  system,  and  that 
the  virus  acts  primarily  upon  the  lymphatics  and  epithelial  cells,  inflam- 
mation of  the  surrounding  tissues  being  only  secondary. 

He  considers  that  the  contaminating  pus  passes  through  the  epithelial 
cells  by  imbibition,  and  comes  in  contact  with  the  interior  of  the  superfi- 
cial capillary  lymphatics  ;  specific  action,  perhaps  a  primitive  necrosis  of 
epithelial  cells,  is  thus  set  up ;  this  action  propagates  itself  along  the  cap- 
illaries ;  the  epithelial  surface  is  invaded  nearer  and  nearer  ;  the  secre- 
tion of  mucus  is  augmented  ;  the  epithelial  cells  of  the  deeper  layers  are 
incompletely  developed  ;  the  superficial  cells  are  detached  ;  the  lymphatic 
network  is  destroyed,  and  the  mucous  membrane  is  more  or  less  denuded. 
In  the  secretion  are  found  cells  of  pavement  epithelium,  little  many-sided 
cells,  granular  globules  showing  multiple  nuclei  when  treated  with  acetic 
acid,  blood-globules,  and  fine  yellowish  granular  bodies. 

The  disease  continues  to  spread  in  surface  and  depth  from  the  superfi- 
cial to  the  submucous  network.  In  the  deep  or  submucous  lymphatics 
blennorrhagia  is  seldom  suppurative  or  destructive  ;  it  is  really  an  internal 
lymphitis  of  the  submucous  layer.  The  acuteness  and  violence  of  the 
disease  are  in  direct  relation  to  the  number  of  the  canals  and  the  close- 
ness of  the  meshes.  Very  intense  superficially  in  the  navicular  fossa  and 
the  prostatic  region,  where  autopsy  always  reveals  the  most  vivid  redden- 
ing, it  is  milder  at  the  surface  in  the  spongy  region,  but  more  intense 
again  in  the  submucous  tissue  of  this  region  where  the  deep  mesh  is 
closer.  It  is  here  that  we  find  a  certain  degree  of  resistance  in  the  mu- 
cous membrane,  resistance  which  is  looked  upon  as  due  to  plastic  infiltra- 
tion, but  is  only  the  result  of  irritation  set  up  in  the  mesh  and  surround- 
ing connective  tissue.  The  epithelial  necrosis  extends  neither  to  the 
bladder  nor  to  the  glands  of  Cowper,  to  the  prostatic  canaliculi  nor  the 
ejaculatory  ducts.  It  stops  abruptly  at  their  borders  where  it  forms  a  sel- 


PATHOLOGY.  37 

Tage.  On  the  other  hand,  the  disease  constantly  invades  the  glands  of 
Littre,  the  excretory  canal  of  which  is  laid  with  pavement  epithelium. 

Blennorrhagia  terminates  in  necrotic  destruction  of  the  epithelium  and 
the  lymphatic  canals,  and  the  reproduction  of  these  by  the  generation  of  a 
normal  epithelium,  but  probably  in  smaller  quantity  ;  the  latter  fact  being 
the  cause  why  a  second  gonorrhoea  is  milder  than  the  first.  Relapses  are 
explained  by  the  persistence  of  diseased  action  in  the  deep  lymphatic  bed, 
from  which  it  again  reaches  the  superficial  mesh  when  this  has  been  re- 
generated ;  or  it  may  happen  that  a  portion  of  this  mesh  hitherto  healthy 
is  tainted  by  an  infected  part.  The  reason  why  abortive  injections  do  not 
succeed  is  that 'they  do  not  reach  the  submucous  lymphatics.  The  gonor- 
rhoea! infection,  following  the  route  indicated,  may  reach  the  dorsal  trunks 
of  the  lymphatics  of  the  penis,  and  there  excite  lymphitis  ;  it  may  also  ex- 
tend to  the  ganglia  of  the  groin  and  pelvis,  the  layer  of  pavement  epither 
lium,  which  constitutes  the  wall  of  the  capillary  lymphatics  and  forms  the 
internal  coat  of  the  lymphatic  vessels,  being  the  conducting  agent. 

This  much  relates  to  the  course  of  simple  uncomplicated  gonorrhoea  at 
the  outset.  The  question  of  extension  of  the  morbid  action,  us  the  first 
stage  in  the  pathology  of  orchitis,  will  necessarily  come  under  discussion 
in  the  part  treating  of  that  affection,  as  also  in  that  relating  to  gleet. 

Period  of  Incubation. — This  has  been  so  variously  stated  that  if  we  al- 
low equal  weight  to  all  who  have  given  us  the  result  of  their  observations, 
no  time  can  very  well  be  laid  down.  It  is,  of  course,  very  often  a  most 
important  question  for  the  patient's  peace  of  mind  to  know  at  the  expira- 
tion of  what  term  he  may  fairly  calculate  on  escaping  from  the  results  of 
indiscretion  ;  but  really  the  question  is  not  very  easily  answered,  and  I  be- 
lieve the  only  safe  way  of  dealing  with  it  is,  if  we  include  after-infections, 
to  extend  the  limit  beyond  that  often  laid  down  in  works.  In  the  case  of  a 
first  gonorrhoea,  the  symptoms,  though  slight,  usually  set  in  quite  unmis- 
takably at  the  end  of  three,  four,  or  five  days.  The  contention  that  there 
is  no  proper  period  of  incubation  in  gonorrhoea,  that  what  is  so  called  is 
only  a  time  of  latent  action,  in  which  the  morbid  phenomena  are  develop- 
ing without  being  intense  enough  to  make  themselves  visible,  is  one  of  the 
most  extraordinary  I  ever  heard  of  ;  for  what  is  this  latent  action  without 
visible  results  but  incubation  itself,  and  what  proof  is  there  that  the  very 
same  action  is  not  going  on  from  the  time  of  infection  in  small-pox  and 
scarlet  fever  ? 

According  to  M.  Le  Fort,1  out  of  2,070  patients  suffering  under  gonor- 
rhoea, 778  noticed  the  initial  symptoms  of  the  disease  within  the  first  four 
days,  50  of  them  at  the  end  of  twenty-four  hours  after  exposure  to  infec- 
tion, and  869  in  the  second  four  days ;  276  noticed  the  earliest  signs  be- 
tween the  close  of  the  eighth  and  of  the  twelfth  day  ;  112  in  the  fourth 

1  Medical  Times  and  Gazette,  vol.  ii. ,  p.  52.     1869. 


38  ON    GONORRHOEA. 

period  of  four  days,  and  only  17  in  the  fifth  of  these  periods,  or  from  the 
sixteenth  day  to  the  twentieth,  including  the  latter.  Supposing  these  sta- 
tistics to  represent  average  results,  the  first  symptoms  must  be  considered 
to  appear,  in  upward  of  seventy-eight  per  cent,  of  all  the  cases,  in  the  time 
extending  from  the  first  to  the  ninth  day.  But  often  enough  in  after-at- 
tacks the  symptoms  appear  much  later,  and  not  infrequently  in  so  insidious. 
a  manner  that  both  surgeon  and  patient  at  first  look  upon  what  is  destined 
to  ripen  into  a  true  gonorrhoea,  as  "  a  mere  touch  of  gleet."  Hunter  gives l 
the  time  as  varying  from  a  few  hours  to  six  weeks,  and  if  no  regard  be  paid 
to  the  difference  between  a  mild  and  a  sharp  case,  a  first  attack  and  one 
preceded  by  many  others,  this  rough  estimate  may  hold  good.  I  have,  how- 
ever, never  seen  any  approach  to  such  a  long  duration. 

An  opinion  that  gonorrhoea  is  more  liable  to  relapse  at  certain  times  of 
the  year  than  at  others  has  been  advanced  by  some  authors.  M.  Robert 
says  that  the  spring  seems  greatly  to  favor  relapses,  and  I  have  fancied 
I  detected  something  of  the  tendency  myself  during  the  prevalence  of  cold, 
dry  east  winds.  The  question,  however,  is  difficult  to  settle  till  we  have 
much  better  data.  If  the  mere  revolution  of  seasons  influenced  the  num- 
ber of  cases,  we  might  expect  a  regularly  recurring  increase  in  spring,  and 
of  this  I  have  not  as  yet  seen  any  proof  worth  notice. 

Seat  of  Gonorrhoea  in  the  Female. — As  concerns  the  seat  of  this  disor- 
der, and,  by  implication,  the  relative  frequency  of  its  different  forms  in 
women,  I  should  say,  judging  from  my  own  practice,  that  the  vagina  is  the 
chief  place  of  action  in  the  first  attack  ;  that  in  some  instances  the  morbid 
action  spreads  to  the  urethra,  and  fastens  on  it  with  such  severity  as  to 
make  this  the  predominant  affection  ;  and  that  in  neglected  cases,  or  after 
repeated  infections,  some  degree  of  mischief  will  usually  be  found  near  or 
on  the  os  uteri,  most  likely  with  some  exudation  from  the  canal  of  the  cer- 
vix. Dr.  Ashwell  held  that  gonorrhoea  in  women  is  chiefly  seated  in  the 
vagina,  and  Dr.  Tyler  Smith  agrees  with  him.  Out  of  112  cases,  Egan 
found 2  the  vagina  more  or  less  inflamed  in  98,  granular  erosion  on  the  cer- 
vix in  38,  erythematous  condition  of  the  os  or  cervix  in  57,  and  the  uterus 
participating  in  97.  Dr.  Graily  Hewitt  considers 3  that  when  the  vagina  is 
attacked  with  acute  gonorrhoea,  the  urethra  frequently  shares  in  the  mor- 
bid action.  According  to  the  opinion  of  Dr.  Barnes,  a  most  truthful  and  la- 
borious observer,  quoted  in  Jones  and  Sieveking's  "  Pathological  Anatomy," 
gonorrhceal  vaginitis  more  particularly  affects  the  fundus  of  the  vagina, 
with  some  implication  of  the  vaginal  portion  of  the  uterus  ;  the  redness  is 
much  more  intense  than  in  the  simple  form,  and  the  gonorrhceal  variety 
yields  a  copious  muco-purulent  secretion  of  greenish  or  yellowish  tint. 
Hagemann  contends  *  that  the  urethra  and  glands  of  Bartholini  most  fre- 

1  Op.  citat.,  p.  31.  8  Dublin  Quarterly  Journal,  vol.  v.,  p.  408. 

3  British  Medical  Journal,  vol.  i.,  p.  57.     1862. 

4  Wiener  mediziuische  Wochenschrift,  S.  606.     1879. 


PATHOLOGY.  39 

quently  of  all  parts  take  on  the  gonorrhceal  action.  In  703  cases  of  gonor- 
rhoea he  found  urethritis  in  409  and  Bartholinitis  (sic)  in  383.  The  state- 
ment is  in  direct  conflict  with  the  experience  of  M.  Bonniere,1  who  could 
never  in  acute  blenuorrhagia,  even  when  it  had  lasted  several  days,  detect 
any  pus  in  the  glands,  all  he  could  extract  by  pressure  being  a  little 
stringy  viscid  mucus.  The  latter  writer  maintains  that  the  inflammation 
of  the  interior  of  the  neck,  however  virulent,  does  not  extend  beyond  the 
part  covered  with  pavement  epithelium,  that  is  to  say,  the  lower  portion. 
It  is  sharply  arrested  there,  the  boundary  being  quite  definitive.  In  front 
of  the  os  tincse  the  lymphatic  network  is  loose,  and  the  gonorrhceal  action 
there  is  mild  ;  behind,  the  meshes  are  closer  and  there  it  is  more  virulent 
and  persistent,  an  anatomy  which  needs  confirmation. 

Period  of  Incubation. — The  time  at  which  the  signs  of  infection  appear 
in  the  female  is  by  no  means  easy  to  decide.  The  hidden  site  of  the  part, 
and  the  ignorance  of  many  women  as  to  the  nature  of  the  complaint,  and, 
indeed,  of  such  things  in  general,  make  it  more  difficult  to  fix  the  era  of 
its  outbreak  with  exactness  ;  but  the  probability  is  that  it  is  much  the 
same  as  in  men. 

Milder  Nature  of  Gonorrhoza  in  Subsequent  Attacks. — Hunter  held 2  that 
most  men  suffer  more  severely  in  the  first  gonorrhoea,  and  that  "  the  suc- 
ceeding ones  generally  become  milder  and  milder  till  the  danger  of  infec- 
tion almost  vanishes."  Many  authors  have  accepted  and  repeated  the  first 
part  of  this  view,  but  I  am  satisfied  that  on  both  heads  the  statement  is  fre- 
quently at  fault.  It  is  true  enough  that  a  man  who  has  caught  one  sharp 
gonorrhoea,  with  a  good  deal  of  scalding,  chordee,  pain,  and  perhaps 
swelled  testicle  and  irritable  bladder,  does  not  often  present  himself  with 
exactly  the  same  symptoms  ;  partly,  it  may  be,  because,  warned  by  what 
he  has  suffered,  he  takes  more  care  about  his  next  attack,  and  exposes 
himself  less  to  infection.  In  such  a  patient  the  symptoms  will  probably 
enough  be  slighter,  but  often  matters  do  not  go  on  in  this  way. 

Some  persons  suffer  more  in  the  second  attack  than  in  the  first.  One 
of  the  most  refractory  cases  I  ever  had  under  my  care  was  a  second  gonor- 
rhoea ;  according  to  the  patient's  account,  which  was  perfectly  consistent 
throughout,  all  the  symptoms  were  worse  than  in  the  first.  I  have  notes 
of  two  or  three  similar  cases,  including  one  in  which  the  fourth  attack 
was  worse  than  the  first,  and  one  where  the  third  gonorrhoea  was  more 
severe  and  obstinate  than  the  second.  Some  men  always  have  the  disease 
in  a  mild  form,  others  the  very  reverse.  I  had  a  gentleman  three  times 
under  my  care  for  this  complaint ;  it  went  away  very  quickly  in  each  in- 
stance, and  he  assured  me  that,  though  he  had  often  exposed  himself  to 
contagion,  he  had  never  had  a  discharge  which  lasted  more  than  a  week, 
nor  was  the  complaint  ever  attended  by  such  symptoms  as  chordee.  On 

1  Op.  citat.,  p.  408.  !  Op.  citat.,  p.  37. 


40  ON    GONORKHCEA. 

the  other  hand,  I  treated  a  patient  for  eleven  gonorrhoeas  in  three  years, 
in  none  of  which  did  I  notice  any  symptoms  of  abatement,  there  being  a 
good  deal  of  running,  redness  of  the  urethra,  scalding,  and  disposition  to 
chordee  at  each  attack.  All  were  cured  very  quickly,  but  for  anything  I 
could  make  out  to  the  contrary,  the  last  attack  was  as  bad  as  any  of  the 
others.  Irrespective  of  this  evidence  that  we  cannot  always  rely  on  the 
danger  of  infection  "  almost  vanishing,"  I  may  add  that  I  was  once  con- 
sulted about  a  case  where  the  patient,  in  his  written  account,  roughly  com- 
puted the  number  of  his  infections  at  thirty. 

Does  Gonorrhoea  Infect  the  System.  ? — Dr.  Tanner  says  that  the  occur- 
rence of  such  a  disease  as  gonorrhceal  rheumatism  can  only  be  explained 
on  the  supposition  of  systemic  infection.  I  am  not  quite  clear  that  I  un- 
derstand exactly  what  systemic  infection  is.  Extension  of  the  purulent 
inflammation,  Hunter's  sympathy  of  continuity,  either  in  all  its  integrity 
or  in  a  modified  form,  may  be  imagined  as  possible  all  along  the  mucous 
membrane  of  the  genito-urinary  tract ;  indeed,  there  is  every  reason  to 
believe  that  it  takes  place  sometimes.  Again,  inflammation  of  the  con- 
tiguous parts  (sympathy  of  contiguity)  is  clearly  excited  by  gonorrhoea, 
and  is  comprehensible  enough  ;  while  endocarditis,  rheumatism,  and  puru- 
lent deposit  in  distant  parts  show  that  a  series  of  different  and  yet  very 
serious  actions  may  be  set  up.  But  I  see  neither  proof  nor  possibility  of 
the  whole  frame  being  affected ;  of  the  lungs,  brain,  heart,  liver,  muscles, 
and  bones  being  enveloped  in  one  common  mass  of  disease,  and  yet  this 
is  what  systemic  infection  must  mean,  if  it  mean  what  it  professes  to  do. 
Possibly  Hunter's  "  remote  sympathy,"  of  which  he  gave  some  instances, 
and  of  which  I  think  many  more  might  be  given,  offers  a  clue  to  the  solu- 
tion of  the  problem,  the  action  indeed  being  strictly  reflex.  MM.  Pidoux 
and  Guerin  believe  in  the  existence  of  a  species  of  gonorrhoea!  lues,  and 
M.  Fereol  rather  leans  '  to  this  opinion,  which  seems  to  me  about  as  un- 
founded as  anything  in  the  shape  of  an  opinion  can  well  be. 

Prognosis. — According  to  some  writers,  gonorrhoea  is  so  mild  a  com- 
plaint as  scarcely  to  require  any  rules  for  treatment.  I  heard  a  consulting 
surgeon,  in  large  practice,  assert  that  he  always  cured  his  patients  in  a 
week  or  ten  days.  Dr.  Chambers,  of  St.  Mary's  Hospital,  considers 2  that 
gonorrhoea  is  never  obstinate  or  of  long  duration,  unless  rendered  so  by 
bad  treatment  on  the  part  of  the  surgeon,  or  folly  on  that  of  the  patient 
Like  a  mild,  catarrh  it  passes  off  of  its  own  accord,  if  the  patient  will  only 
be  reasonably  quiet  and  the  surgeon  abstain  from  mischievous  interference. 
The  reader  must  bear  in  mind  that  these  assertions  are  not  made  by  any 
mere  tyro,  but  by  a  physician  to  a  large  hospital,  a  Lumleian  lecturer,  and 
a  well-known  author. 

1  Archives  Generates  de  Medeciue,  tome  ii.,  p.  208.    1866. 
1  Lancet,  vol.  i.,  p.  582.    1861. 


PATHOLOGY.  41 

This  view  does  not  in  any  way  harmonize  with  my  experience,  which  is 
that  many  cases  of  gonorrhoea  are  only  subdued  with  great  difficulty.  It 
is  in  direct  conflict  with  the  experience  of  Lee,1  Astley  Cooper,2  Bumstead,3 
Durkee,4  Hunter,0  Johnson,6  Robert,7  and  Fournier  ;  in  'fact  of  every  one 
who  has  carefully  studied  the  disease  and  written  honestly  about  it.  They 
tell  us  that,  with  rare  exceptions  the  disease  requires,  under  the  best  man- 
agement, three  or  four  weeks,  often  as  many  months,  to  cure,  and  that  it 
is  impossible  to  fix  a  reliable  average  date  for  the  duration  of  gonorrhoea. 

Results  of  Gonorrhoea. — As  it  formed  no  part  of  my  plan  to  describe  the 
symptoms  of  this  affection,  inasmuch  as  they  have  been  fully  and  carefully 
laid  down  in  many  excellent  works,  so  for  a  similar  reason,  I  did  not  intend 
to  touch  npon  the  results  it  induces.  But  as  accounts  of  the  effects  pro- 
duced by  this  disease  have  appeared,  which  are  enough  to  make  one's  hair 
stand  on  end,  I  have  been  obliged  to  break  through  the  rule  laid  down. 
They  are  from  the  pen  of  Dr.  Noeggerath,  of  New  York,8  who  informs  us 
that  gonorrhoea,  in  man  as  in  woman,  once  contracted,  is,  as  a  rule,  incur- 
able ;  that  it  renders  every  man  who  has  suffered  from  it  to  a  great  extent 
sterile,  and  that  eight  out  of  every  ten  men  have  gonorrhoea.  The  wives 
of  men  who  have  contracted  this  disease  either  remain  barren,  or,  if  they 
become  pregnant,  abort  or  bear  only  one  child.  He  gives  the  cases  of 
eighty-one  women  thus  situated.  Out  of  these  only  thirty-one  conceived. 
Five  of  the  thirty-one  aborted,  and  three  were  prematurely  confined,  thus 
reducing  the  number  of  child-bearing  women  to  about  one-fourth  of  all 
who  married.  Of  the  twenty-three  who  went  their  full  time,  twelve  had 
one  child  during  married  life,  seven  had  two  children,  three  had  three,  and 
one  had  four.  I  am  indebted  for  a  knowledge  of  these  startling  facts  to  a 
review  of  the  work  in  the  Edinburgh  Medical  Journal,9  for  I  have  not  seen 
the  original,  and  I  may  observe  that  the  reviewer  seems  rather  favorably 
disposed  toward  Dr.  Noeggerath's  opinions,  and  speaks  of  the  work  as  a 
thoughtful  and  important  essay  ;  a  sentiment  evidently  shared  by  the  re- 
viewer in  the  Dublin  Quarterly  Journal,10  who  describes  the  book  as  inviting 
"the  most  careful  consideration  of  the  subject." 

But  the  troubles  of  women  who  have  the  misfortune  to  marry  the  vic- 
tims of  gonorrhoea  do  not  end  here.  Nine  out  of  ten  of  them  fall  into 
some  incurable  kind  of  disease  such  as  perirnetritis,  acute,  chronic,  or  recur- 
rent ;  oophoritis,  and  catarrh  of  the  genital  passages.  Finally  the  infection 
of  gonorrhoea  is  so  intense,  that  it  may  be  conveyed  when  the  disease  is 
latent.  Complaints  are  sometimes  made  that  we  get  nothing  new  about 
this  disorder.  Here  at  any  rate  is  novelty  enough. 

It  does  not  seem  to  have  struck  Dr.  Noeggerath  that,  had  his  facts  been 

1  Op.  citat.,  p.  195.  2  Lancet,  vol.  iii.,  p.  104.       3  Op.  citat.,  pp.  63,  100. 

4  Op.  citat.,  p.  43.  6  Op.  citat.,  p.  69.  6  Op.  citat.,  p.  86. 

1  Op.  citat.,  p.  81.  8Die  latente  Gonorrhoe  im  weiblichen  Geschleclite. 
9  Vol.  xviii.,  p.  648.  10  Vol.  Ivii.,  p.  326. 


42  ON    GONOERHCEA. 

correct,  gonorrhoea  would  have  long  ago  depopulated  every  country  into  which 
it  had  penetrated.  According  to  him  eighty  out  of  a  hundred  men  catch 
gonorrhoea,  and  we  have  just  seen  that  eighty-one  such  men  have  thirty- 
one  children.  Suppose  that,  for  convenience  sake,  we  take  eighty-one  out 
of  a  hundred,  instead  of  eighty,  as  representing  the  proportion  of  infected 
males  ;  doing  so  will  not  materially  affect  the  issue,  and  a  second  calcula- 
tion by  the  reader  will  at  any  time  set  all  right.  If,  to  the  remaining  nine- 
teen we  allot  an  aggregate  of  a  hundred  children,  which  is,  I  believe, 
quite  up  to  the  average,  this  will  give  us  a  total  of  a  hundred  and  thirty- 
nine  children  born  to  every  two  hundred  grown  up  persons.  It  needs  no 
reference  to  an  actuary  to  show  that,  with  such  a  state  of  matters,  the  dis- 
appearance of  the  entire  population  is  only  a  question  of  time,  and  of  a 
very  short  time  too. 

Again,  out  of  every  hundred  married  women,  seventy-two  must,  accord- 
ing to  Dr.  Noeggerath's  theory,  suffer,  sooner  or  later,  under  incurable  dis- 
ease of  the  womb,  the  surrounding  parts  and  appendages,  and  the  genital 
passages.  This  is  the  percentage  from  gonorrhoea.  Add  to  this  the  cases 
where  either  such  affections,  or  other  formidable  diseases  of  these  parts,  are 
brought  on  by  more  innocent  causes,  and  we  are  driven  to  the  conclusion, 
that  out  of  every  hundred  married  women,  nearly  eighty  at  least  are  suffer- 
ing under  severe  or  hopeless  uterine  disease.  I  think  I  may  safely  ask, 
whether  there  is  a  man  living  whose  experience  agrees  with  that  of  our 
author. 

His  statement,  too,  about  the  sterility  of  men  who  have  once  had  gon- 
orrhoea, does  not  harmonize  with  what  I  have  seen ;  on  the  contrary,  I  know 
cases  enough  which  prove  the  very  reverse.  I  attended  a  gentleman  who 
had,  he  told  me,  been  repeatedly  infected.  He  had  gonorrhoea  to  a  cer- 
tainty ;  I  saw  the  pus  coming  out  of  the  urethra,  and  injected  him  with  my 
own  hands.  Two  or  three  years  after  this  he  married,  and  his  wife  had 
twins  at  her  first  confinement  Both  lived,  and  are  now  fine  sturdy  lads. 
When  I  last  saw  him  his  wife  was  again  pregnant.  I  was  consulted  about 
the  case  of  a  gentleman  whose  brother,  himself  a  surgeon,  told  me  that  this 
patient  had  in  his  younger  days  so  repeatedly  suffered  from  gonorrhoea,  that 
he  believed  it  was  rather  the  rule  than  the  exception  for  him  to  have  one. 
After  marriage  he  had  four  healthy  children,  the  somewhat  advanced  age 
of  his  wife  seemingly  alone  preventing  any  further  increase  of  family.  I 
attended  two  gentlemen,  friends  of  each  other.  One  of  them  had  as  bad 
a  gonorrhoea  as  ever  I  saw  and  extremely  rebellious.  He  has  now  five  fine 
children,  one  of  them  growing  up  quite  a  type  of  manly  beauty.  His 
friend  had  eight  attacks  of  gonorrhoea,  for  three  of  which  I  attended  him  ; 
he  has  since  married  twice,  and  had  children  by  each  wife,  the  number 
amounting  to  six  when  I  last  heard  of  him.  My  opinion  was  asked 
about  a  case  of  somewhat  alarming  bleeding  from  the  urethra,  owing  to 
chordee  from  gonorrhoea.  The  patient  married  directly  after  he  was 


PATHOLOGY.  43 

cured,  and  has  had  fourteen  children,  twelve  of  whom  are  now  living,  and 
so  on. 

Nor  am  I  any  more  in  accord  with  this  gentleman  as  to  the  serious 
state  of  health  induced  in  the  female  by  marriage  with  a  man  who  has 
been  infected.  In  many  cases  I  have,  of  course,  had  no  chance  of  learning 
the  history  of  the  case  after  my  attendance  on  the  husband  came  to  an 
end ;  but  in  several  others  I  know  that,  GO  far  as  their  own  repeated  state- 
ments can  inform  me,  the  wives  have  remained  free  from  not  only  uterine 
but  any  other  grave  disease.  I  have  not  heard  that  one  of  them  aborted 
or  was  prematurely  confined,  and  I  am  sure  that  many  have  not  done  so. 

Dr.  Angus  Macdonald,  who  thinks  Dr.  Noeggerath  has  got  hold  of  "  a 
grand  idea,"  has  gone '  very  carefully  into  his  views,  and  quotes  from  his 
own  practice  cases  which  he  thinks  support  the  theory.  Want  of  space 
will  not  allow  me  to  reproduce  these,  and  I  must  therefore  refer  the  reader 
to  Dr.  Macdonald's  paper,  and  especially  to  his  fourth  and  fifth  cases.  So 
far  as  I  can  understand  the  question,  he  seems  only  to  establish  the  fact 
that  gonorrhoea,  even  when  of  long  standing  and  almost  cured,  may  be 
communicated,  a  fact  which  I,  for  one,  never  denied.  In  a  former  edition 
of  this  work  I  called  attention  to  the  possibility  of  the  disease  being  trans- 
mitted by  a  discharge  seemingly  innocuous.  Dr.  Macdonald  also  shows 
that  gonorrhoea,  thus  conveyed,  may  set  up  very  serious  if  not  fatal  con- 
sequences in  pregnant  women.  Not  having  had  much  experience  of  such 
cases,  I  can  offer  no  opinion  on  the  matter.  One,  about  which  I  was  con- 
sulted, rather  supports  Dr.  Macdonald.  The  husband  was  certainly 
laboring  under  recently  contracted  gonorrhoea,  and  infected  his  wife  about 
the  mid-term  of  pregnancy.  Shortly  after  she  was  attacked  by  serious 
symptoms,  which  the  medical*  gentleman  in  attendance  upon  her  seemed 
to  have  considered  as  inflammation  of  the  womb,  but  I  did  not  receive  the 
account  from  him,  and  could  not  get  any  more  definite  statement. 

But  while  I  readily  admit  the  contagious  power  of  even  a  very  slight 
amount  of  pus  in  the  secretion  of  the  male  urethra,  I  entirely  demur  to 
such  a  doctrine  as  that  of  latent  gonorrhoea,  in  the  strict  sense  of  the  word, 
being  conveyed  by  sexual  intercourse  ;  for  by  latent  I  understand  that 
state  in  ivhich  there  is  no  discfiarge  existing.  I  have  already  given  my  rea- 
sons for  coming  to  this  conclusion.  Dr.  Macdonald,  however,  interprets2 
latent  as  chronic  gonorrhoea,  and  from  what  Dr.  Noeggerath  says,  of  its  be- 
ing a  common  practice  to  sanction  the  marriage  of  young  men  stih1  suffer- 
ing un:ler  stickiness  of  the  urethral  opening,  accompanied  by  such  an 
amount  of  discharge  as  to  cause  spots  on  the  linen,  it  is  possible  that  he 
means  the  same  thing ;  but  I  must  take  the  liberty  of  calling  this  gleet, 
not  latent  gonorrhoea,  and  of  adding,  by  way  of  rider,  that  any  medical 
man  sanctioning  marriage  under  such  circumstances  takes  upon  himself 

1  Edinburgh  Medical  Journal,  vol.  xviii. ,  p.  1086.  -  Op.  citat. ,  p.  1101. 


44  ON    GONORRHOEA. 

a  most  dangerous  responsibility.  Rightly  or  wrongly,  I  have  always  under- 
stood by  latent  gonorrhoea,  or  latent  gleet,  a  disposition  in  the  urethra, 
unaccompanied  by  the  presence  of  purulent  secretion,  to,take  on  the  character- 
istics of  gonorrhoea,  or  gleet,  when  the  system  is  excited  by  the  stimulus 
of  much  connection,  indulgence  in  beer,  etc. 

I  do  not  see  how  Dr.  Noeggerath's  assertion  about  gonorrhoea  being  in- 
curable is  to  be  met  at  all.  A  man  might  say  the  same  thing  about  any 
complaint,  without  its  being  possible  for  another  person  to  refute  him  ; 
but  I  believe  I  am  warranted  in  affirming  that  morbid  anatomy  does  not 
come  to  his  assistance  here,  as  it  does  not  demonstrate  any  change  of  tissue 
induced  by  uncomplicated  gonorrhoea,  when  cured  in  the  ordinary  sense 
of  the  term.  What  proof  of  cure  is  to  be  required,  beyond  a  return  to 
natural  appearance  and  natural  state  of  secretion,  I  do  not  know. 

Dr.  Thorburn,  who  investigated  the  subject,  and  for  this  purpose  col- 
lected the  statistics  of  eighty-one  private  families,  found '  that  there  had 
been  thirty-three  per  cent.,  or  twenty-six  in  all,  of  gonorrhoeal  infection  in 
the  male  ;  and  taking  all  the  cases  of  abortion,  sterility,  uterine  and  pelvic 
inflammations  which  had  occurred  in  these  eighty-one  families,  he  showed 
conclusively  that  there  was  the  merest  fractional  difference  in  their  pro- 
portion between  the  previously  and  not  previously  infected  classes.  As 
regards  inflammatory  pelvic  affections,  the  balance  was  fractionally  in  favor 
of  the  "free  gonorrhoeic  cases; "in  other  respects  equally  fractional  in 
favor  of  the  non-gonorrhceal ;  results  which  I  do  not  feel  quite  assured 
about  understanding  very  clearly.  Dr.  Thorburn's  conclusion  is  that  the 
latent  gonorrhoea  of  Dr.  Noeggerath  is  a  myth,  and  not  an  impervious  bar- 
rier to  marriage  as  it  otherwise  would  be.  Dr.  Bantock,  who  was  present 
when  this  paper  was  communicated  to  the  'British  Medical  Association, 
agreed  on  the  whole  with  Dr.  Thorburn  ;  and  added  that  he  did  not  find 
that  women,  who  had  contracted  gonorrhoea,  went  through  pregnancy  any 
worse  than  those  who  had  not  had  the  disease.  I  am  glad  to  find  that  Dr. 
Thorburn  has  refuted  the  theory  from  this  point  of  view,  but  with  all  be- 
coming deference  I  must  urge  that  my  own  arguments,  long  previously 
made  public,  appear  to  me  quite  sufficient  to  subvert  it ;  for  that  which  is 
shown  to  be  impossible  could  never  have  occurred. 

A  case  in  which  serious  nervous  symptoms  followed  gonorrhoea  is  fur- 
nished by  Dr.  Althaus."  The  urethritis  was  obstinate,  and,  having  long 
resisted  injections,  seems  to  have  been  at  last  arrested  by  tannin  bougies. 
Some  months  after,  the  patient  having  married  and  had  connection  with 
his  wife,  was  seized  with  intense  pain  in  the  back  part  of  the  urethra,  and 
on  one  occasion  the  semen  was  tinged  with  blood.  This  was  followed  by 
wearying  pain  occupying  the  whole  of  the  lumbar  region,  which  fre- 

1  British  Medical  Journal,  vol.  ii.,  p.  259.     1877. 
'Medical  Times  and  Gazette,  vol.  i.,  p.  385.    1807. 


PATHOLOGY.  45 

quently  radiated  into  the  groins,  hips,  and  thighs.  It  never  left  him,  and 
was  liable  to  be  increased  by  all  kinds  of  exercise.  Then  followed  perma- 
nent pain  in  the  urethra,  irritability  of  the  bladder,  and  occasionally 
retention  of  urine  ;  bad  appetite,  imperfect  assimilation,  pain  in  the  back, 
lassitude,  tremor,  frequent  jerkings,  pains  shooting  through  the  legs, 
and  sense  of  numbness  in  the  feet.  The  treatment  consisted  of  catalec- 
trotonus  of  the  spine  and  passes  with  the  cathode  over  the  entire  lumbar 
region,  while  the  anode  was  placed  upon  the  perineum  to  act  on  the  pain- 
ful part  of  the  urethra.  A  rapid  cure  followed,  the  pain  especially  being 
quickly  relieved. 

Such  results  as  these  are  so  rare  as  to  make  their  classification  unde- 
sirable, and  it  is  not  quite  certain  that  they  were  really  due  to  the  gonor- 
rhoea at  all ;  I  have  therefore  preferred  to  take  the  case  here  rather  than 
among  the  complications  of  gonorrhoea,  which  I  need  hardly  say  are  in 
reality  results  of  this  disorder.  Some  very  serious  diseases,  however,  such 
as  gonorrhceal  peritonitis,  sub-peritoneal  inflammation,  endocarditis,  etc., 
which  appear  to  be  extensions  of  common  well-known  complications,  will 
be  considered  further  on  in  connection  with  gonorrhceal  rheumatism,  affec- 
tion of  the  seminal  vesicles,  and  so  on. 

Origin  of  Gonorrhoea  from  a  Fungus. — As  most  of  my  readers  are  no 
doubt  aware,  this  disease  has  at  different  times  been  ascribed  to  the  oper- 
ation of  a  fungus,  and  especially  by  Dr.  Salisbury,  who  tells  us  '  that  the 
species  which  produces  gonorrhoea  consists  of  spores,  which  are  found  in 
pairs  and  sometimes  in  fours,  and  develop  rapidly  in  and  among  the  pa- 
rent cells  of  the  mucous  membrane.  These  spores  unite  and  run  into  fila- 
ments. He  also  maintains,  that  if  this  fungus  be  once  planted  in  the 
raucous  membrane,  it  "  extends  from  cell  to  cell,  if  not  prevented  by  re- 
medial means,  till  it  has  invaded  all  the  mucous  surfaces  in  continuity 
with  each  other."  I  presume  this  really  means,  that  in  every  case  where 
gonorrhoea  is  not  checked  by  art,  it  spreads  to  the  bladder,  ureters,  and 
epididymis.  I  ask  the  reader  to  weigh  this,  and  say,  whether  he  has  not 
often  seen  a  neglected  gonorrhoea  where  nothing  of  the  kind  took  place. 
The  purely  microscopical  view  of  the  question  is  carefully  considered, 
and  I  think  refuted,  in  the  first  volume  of  the  Archio  far  Dermatologie, 
where  also  the  statements  of  Hallier  on  the  same  subject  are  discussed. 
Long  ago  indeed  M.  Jusseaume,  in  his  inaugural  thesis  defended  before  the 
Faculty  at  Paris,  1862,  maintained  2  that  gonorrhoea  is  clue  to  a  vegetable 
parasite,  ftn  alga,  consisting  of  long  filaments  ten  to  twenty  millimetres  in 
thickness,  and  often  curved  or  bent  at  an  angle.  He  described  minutely 
the  changes  which  take  place  in  these  bodies,  as  also  their  reproductive 
organs,  showing  to  what  an  extent  self-deception  may  be  carried  by  means 
of  the  microscope. 

1  American  Journal  of  the  Medical  Sciences,  vol.  lv.,  p.  22. 
1  Archives  Gent-rales  de  Medeciue,  tome  i. ,  p.  353.     1863. 


46  ON    GONORRHCEA. 

Micrococcus  Peculiar  to  Gonorrhcea. — Dr.  Albert  Neisser,  of  Breslau, 
reports l  that  he  has  discovered  a  body  of  this  nature  which  may  be  found 
by  the  following  process.  The  thinnest  possible  layer  of  gonorrhceal  mat- 
ter having  been  dried  on  the  slide,  and  colored  by  pouring  over  it  watery 
solution  of  methyl-violet,  is  then  examined  by  means  of  a  high  power  with 
the  largest  diaphragm  opening  (mit  wenigst  moglich  abgeblendetem 
Licht).  Neisser  himself  uses  for  the  purpose  a  Zeiss  microscope  with 
Abbe's  lighting  apparatus,  one-twelfth  oil  immersion  lens  and  four  or  five 
ocular,  a  clearer  view  being  thus  obtained  than  with  the  best  immersion 
of  Hartnack  and  Siebert.  At  the  first  glance  may  be  seen,  besides  the 
dark  violet  blue  of  the  pus-corpuscles  appearing  in  the  most  varied 
shape,  and  revealing  even  their  dull  tinted  protoplasm,  a  number  of  more 
or  less  thickly  set  heaps  of  micrococci,  which  have  a  perfectly  character- 
istic form  and  can  be  immediately  recognized. 

The  individual  bodies  composing  these  masses  are  circular,  and  strik- 
ingly large  ;  they  very  readily  take  the  stain  of  methyl- violet.  They  are 
also  colored  by  strong  solution  of  eosin,  but  do  not  in  this  state  contrast 
so  markedly  with  the  nuclei  of  the  pus.  corpuscles,  which  Ehrlich  indeed 
proposes  to  call  eosinophilous.  They  are  not  affected  by  methyl-green  and 
indulin.  With  objectives  of  lower  power  the  micrococci  are  seen  girdled 
with  a  ring  of  light,  which  perhaps  represents  a  mucous  envelope.  They  are, 
however,  seldom  met  with  solitary  ;  generally  we  find  two  packed  close  to- 
gether, so  close  in  fact  that  they  give  the  observer  the  impression  of  a 
single  body  shaped  like  a  figure  8,  a  biscuit,  or  a  german  roll.  The  seem- 
ing diversity  and  multiplicity  in  the  arrangement  of  these  composite  bodies 
are  best  interpreted  by  attending  to  the  history  of  their  development. 
Thus  the  isolated  micrococcus  is  round,  but  is  soon  transformed  into  a  short 
corpuscle  of  lengthened  oval  shape,  which  quickly  undergoes  constriction  in 
the  middle  and  divides  into  two  micrococci.  Up  to  the  date  of  Dr.  Neisser's 
memoir  it  had  not  been  possible  to  say,  whether  the  preponderance  ob- 
served of  micrococci  of  the  german  roll  (Semmel)  shape  is  due  to  the  acci- 
dentally long  cohesion  of  two  individual  bodies,  or  whether  multiplication 
by  change  is  so  rapid  that  the  individual  is  seldom  seen  in  its  isolated 
stage. 

Finally  the  micrococci  part  company,  and  a  small  space,  equal  to  about 
their  own  bulk,  separates  them  from  each  other.  Each  individual  body, 
however,  speedily  divides  again,  but  this  time  exactly  at  a  right  angle  to 
the  first  Hue  of  scission.  In  this  way  each  half  breaks  up  into  two,  so  that 
frequently  groups  of  four  are  met  with.  For  the  most  part  the  micrococci 
agglomerate  into  columns  of  ten,  twenty  or  more,  each  segregated  by  a 
mucous  envelope,  easily  made  out  when  the  field  is  somewhat  less  clearly 
illuminated.  In  these  colonies  the  micrococci  never  lie  very  close  to  each 

1  Central  Blatt.  f iir  die  medizinische  Wissenschaft,  S.  497.    1879. 


pjrriiOLOGY.  47 

other,  being  always  kept  apart  by  large  spaces  (sic) ;  tliey  are  generally 
found  on  the  upper  surface  of  pus-cells,  seldom  on  epithelial  cells.  Some- 
times the  nucleus  was  found  wanting  in  certain  pus-cells  which  were  beset 
with  micrococci ;  in  others  a  distinct  lessening  of  the  nucleus  could  be 
made  out,  corresponding  to  an  in-growth  of  micrococci  on  the  nucleus.  For 
all  this  Dr.  Neisser  considers  that  the  hypothesis  of  these  growths,  depend- 
ing for  their  existence  on  the  destruction  of  the  nuclei,  must  be  sum- 
marily rejected. 

These  micrococci,  recognized  not  only  by  Dr.  Neisser  but  also  by  other 
observers,  were  found  in  thirty-five  cases  of  gonorrhoea  selected  for  exami- 
nation, the  date  from  the  commencement  of  the  disease  varying  from  three 
days  up  to  thirteen  weeks ;  in  one  case  of  chronic  gonorrhoea  which  had 
lasted  eighteen  months  he  could  not  find  any.  In  general  they  were  met 
with  indifferently,  whether  the  case  had  been  treated  or  not ;  in  five  cases 
persistently  treated  with  sulphocarbolate  of  zinc  he  could  not  detect  any, 
although  the  secretion  was  very  profuse. 

With  the  exception  of  one  case  in  which  there  was  a  strong  suspicion 
of  soft  ulcer  of  the  urethra,  every  specimen  of  gonorrhoea!  pus  which  he 
examined  contained  only  this  kind  of  bacteria.  On  the  other  hand,  this 
form  of  micrococcus  was  absent  in  every  other  kind  of  pus  examined,  how- 
ever rich  such  specimens  might  be  in  bacteria  ;  balano-posthitis,  soft  sore, 
hard  sore,  bubo  of  every  kind,  whitlow,  etc.,  yielded  nothing  of  this  sort. 
The  micrococci  were  also  wanting  in  thirteen  cases  of  fluor  albus  selected 
at  random,  but  were  found  numerous  enough  in  the  vaginal  secretion  of  two 
girls,  who  had  evidently  been  maltreated  by  a  man  suffering  from  gonor- 
rhoea. Exactly  similar  typical  micrococci  were  found  in  nine  cases  of  puru- 
lent urethritis  in  women,  also  in  seven  cases  of  acute  purulent  ophthalmia 
in  new-born  infants,  of  one  to  six  weeks'  duration  of  the  disease.  In  one 
case  of  fourteen  days'  standing,  where  very  energetic  treatment  had  left 
only  a  minimum  of  secretion,  the  micrococci  were  wanting,  as  they  also 
were  in  every  instance  of  simple  purulent  conjunctivitis.  They  were  dis- 
covered in  two  cases  of  gonorrhceal  ophthalmia  in  the  adult. 

Dr.  Neisser  sums  up  by  observing  that  the  micrococci,  which  he  has 
described,  offer  an  unfailing  test  of  the  gonorrhceal  nature  of  affections  of 
the  urethra,  as  also  of  the  eye,  and  thus  enable  us  to  diagnose  the  specific 
character  of  the  discharge.  There  is,  moreover,  no  connection  between 
them  and  the  micrococci  of  the  urine,  which  are  developed  after  a  per- 
fectly different  and  typical  fashion  in  long  chains  and  rows. 

Dr.  F.  Weiss  has  verified '  to  a  great  extent  the  statements  of  Dr.  Neis- 
ser, examining  the  pus  with  diameters  of  2,200, 1,100,  1,000,  and  even  900, 
methyl-violet  having  answered  best  as  a  re-agent  in  his  observations.  He 
describes  the  isolated  bodies  as  almost  spherical,  ten  to  thirteen  tenths  of 

1  Gazette  Hebdomadaire,  p.  751.     1880. 


48  ON    GONOKRH(EA. 

a  millimetre  in  diameter,  each  being  encircled  by  a  hyaline  band  visibly 
striped  ;  they  are,  however,  rarely  seen  solitary.  He  found  these  bodies  in 
the  pus  of  twenty-three  women  and  nine  men  suffering  respectively  from 
gonorrhoea!  vaginitis  and  gonorrhoea,  but  never  in  that  of  simple  urethritis, 
balanitis,  chancre,  bubo,  leucorrhcea,  or  suppurative  orchitis. 

I  suppose  it  is  now  universally  admitted  that  Jusseaume  and  Salisbury 
were  mistaken,  and  perhaps  this  has  made  men  rather  skeptical  about  ac- 
cepting the  discovery  of  Neisser,  for  that  great  skepticism  exists  there  can, 
I  think,  be  no  doubt  ;  and  it  will  not  be  very  satisfactory  to  find  that  time 
has  justified  it,  and  that  the  microscope  has  at  least  thrice  led  careful  in- 
dustrious observers  into  error.  For  my  own  part  I  quite  admit  that,  had 
I  found  out  what  any  of  these  gentlemen  did,  I  should  have  trusted  to  the 
microscope  and  contended  for  the  truth  of  the  discovery. 

Mr.  Watson  Cheyne  '  conveyed  (under  certain  conditions  which,  how- 
ever, he  does  not  specify)  gonorrhoea!  pus  into  infusion  of  meat  and  cu- 
cumber. "  In  these  flasks,"  he  says,  "  inicrococci  grew  in  large  numbers, 
and  also  sometimes  bacteria,  showing  that  these  organisms  were  present 
in  the  gonorrhoea!  pus."  He  also  says,  alluding  to  Dr.  Neisser's  discovery, 
that  "  the  presence  of  large  numbers  of  micrococci  in  gonorrhceal  pus  has 
since  been  confirmed  by  several  observers ; "  it  will  be  noticed,  however, 
that  he  is  silent  as  to  the  question  of  these  bodies  being  peculiar  to  gonor- 
rhoea! pus.  So  far  as  the  evidence  yielded  by  Dr.  Neisser's  observations 
goes,  it  points  to  the  specific  nature  of  gonorrhoea. 

Mr.  Cheyne's  view  is  that  gonorrhoea  may  be  due  to  the  spreading  of 
the  organisms  which  he  describes,  and  then  asks  where  these  are  to  be 
found  ;  so  that  both  the  first  and  second  positions  in  his  argument  are 
purely  conjectural.  Probability  is,  he  thinks,  in  favor  of  the  presence  of 
organisms  in  this  disease,  because  micrococci  have  been  found  in  the  mar- 
gin of  an  erysipelas  patch,  because  gangrene  of  the  tissues  in  mice  is  due 
to  the  presence  of  the  streptococcus,  and  lastly  because  Professor  Lister 
has  come  to  the  conclusion  that  "  the  organisms  "  are  present,  not  only  in 
the  canal  of  a  sinus,  but  in  the  granular  tissue  lining  it.  Having  on  these 
grounds  ascended  from  conjecture  to  probability,  he  in  the  next  page  dis- 
misses all  doubt,  for  after  describing  his  treatment,  he  distinctly  speaks  of 
"the  specific  cause  of  the  disease  being  eradicated  by  these  means."  The 
remedies  he  employs  are  antiseptic ;  but  in  this  case  either  all  remedies 
which  equally  arrest  the'  discharge,  including  such  substances  as  water, 
green  tea,  honey,  and  glycerine,  must  be  included  among  the  antiseptics, 
or  else  the  fact  of  the  discharge  being  arrested  must  be  looked  upon  as 
equally  favoring  any  other  theory.  Tested  by  the  results  of  practice  the 
theory  breaks  down,  as  antiseptics  have  no  particular  control  over  this  dis- 
ease. 

1  British  Medical  Journal,  vol.  ii.,  p.  124.     1880. 


PATHOLOGY.  49 

Varying  Duration  of  Gonorrhoea ;  Connection  between  Inveteracy  and 
Diathesis. — If  twenty  cases  of  gonorrhoea  were  treated  by  the  same  surgeon 
in  exactly  the  same  way,  the  disease  would  almost  certainly  not  run  the 
same  course  in  any  two  of  them,  and  in  all  probability  would  not  be  cured 
in  the  same  number  of  days  in  any  two  out  of  the  twenty.  Very  likely, 
too,  one  of  the  number  would  suffer  from  obstinate  gleet,  while  one  would 
perhaps  be  cured  in  a  visit  or  two.  Of  the  first  of  these  two  anomalies 
various  explanations  have  been  suggested.  Wallace  says,  "  gleet  may 
arise  from  rheumatism,  scrofula,  venereal  poison  ;"  and  again,1  "  such  per- 
sons as  labor  under  gleets  are  sometimes  of  rheumatic  or  scrofulus  habit." 
Howard  expresses  himself  to  much  the  same  effect.  He  says  : 2  "It  is 
always  more  troublesome  in  a  robust  sanguineous  than  in  a  phlegmatic 
habit.  .  .  .  And  the  difference  of  habit  is  still  more  conspicuous  when 
a  disposition  to  scrofula  or  scorbutic  acrimony  is  joined  to  a  young,  robust, 
sanguineous  temperament ; "  and  again  : 3  "  When  a  person  laboring  under 
a  gonorrhoea  is  subject  to  redness,  tenderness,  and  increased  secretion 
from  the  eyelids,  has  a  thickened  upper  lip,  or  redness,  tenderness,  and 
increased  secretion  from  the  glandulse  odoriferse,  such  person  will  proba- 
bly suffer  more,  and  be  cured  with  greater  difficulty  than  another  who  has 
not  any  of  these  affections,  and  that  whether  his  habit  be  weakly  or  robust." 
Mr.  Johnson  thinks 4  he  has  observed  that  "  they  who  have  actually  suffered 
from  scrofula  or  display  the  characteristics  of  that  disease  are  difficult  to 
cure,"  and  M.  Robert b  cites  lymphatic  temperament  and  scrofula  as  incon- 
testably  predisposing  to  gleet ;  while  Fournier  says  that  in  blond  and 
lymphatic  patients  the  disease  may  remain  obstinate  for  months.  Dr. 
Bumstead  also  tells  us s  that  "gleet  is  peculiarly  frequent  and  obstinate  in 
persons  of  a  strumous  diathesis  ;  "  and  Dr.  Dick  says,  "  the  first  thing  a 
practitioner  has  to  do,  when  consulted  for  gleet,  is  to  examine  well  his 
patient  with  respect  to  antecedents,  to  ascertain  if  he  had  a  scrofulous  or 
cutaneous  affection  in  his  early  life,  or  has  been  subject  to  gout  or  rheu- 
matism." 

Of  all  these  authors  not  one  adduces  a  scrap  of  evidence  in  support  of 
his  opinions,  not  one  says  that  he  is  prepared  with  cases  and  statistics  to 
back  up  his  convictions.  The  reader  who  reflects  upon  the  question  must, 
I  imagine,  think  this  rather  strange,  while  it  is  at  least  equally  strange  that 
these  various  causes  should  so  often  produce  one  common  effect.  Gout, 
rheumatism,  and  scrofula,  when  they  exist  in  other  parts  of  the  frame,  run 
a  definite  course,  and  exhibit  a  definite  series  of  symptoms  and  appear- 
ances, which  we  can  usually  influence  to  some  extent  by  medicines.  Con- 
sequently, we  ought  to  have,  among  others,  a  gouty,  rheumatic,  and  scrof- 
ulous gleet,  amenable  to  the  remedies  which  most  surely  act  on  their  re- 

1  A  Treatise  on  the  Venereal  Diseases,  ,p.  283.     1838. 

*  Op.  citat.,  vol.  i.,  p.  211.          3  Ibid.,  vol.  iii.,  p.  42.  4  Op.  citat.,  p.  66. 

6  Op.  citat.,  p.  128.  •  Op.  citat.,  p.  102. 


50  ON    GONORRHOEA. 

spective  diatheses.  Yet  we  cannot  define  or  recognize  any  such  divisions ; 
\ve  find  no  diagnostic  marks  pointed  out  by  which  we  may  distinguish  one 
kind  of  discharge  from  another,  no  attempt  to  treat  any  one  in  the  same 
way  as  a  medical  man  would  treat  a  case  of  gout,  rheumatism,  or  scrofula. 
Half  a  dozen  cases  successfully  managed  by  means  of  colchicum,  lithia,  and 
potass,  salicylates,  or  cod-liver  oil  and  iodine,  would  constitute  a  body  of 
evidence  which  the  most  skeptical  would  scarcely  dare  to  reject ;  but  so  far 
from  anything  of  the  kind  being  forthcoming,  I  have  never  seen  any  reason 
to  believe  that  even  an  attempt  had  been  made  to  cure  gleet  on  such  a  basis, 
looking  rather  as  if  these  gentleman  had  scarcely  so  much  confidence  in 
their  own  opinions  as  to  put  them  to  so  severe  a  test  as  that  of  practice.  It 
will  be  observed  that  there  are  irreconcilable  differences  among  the  authors 
themselves.  Most  of  them  agree  to  admit  scrofula  among  the  causes  of 
inveteracy,  but  they  do  not  agree  upon  any  other  point ;  the  robust,  san- 
guineous habit,  assigned  by  Howard  as  a  reason,  is  the  very  opposite  of  the 
lymphatic  temperament  which  M.  Robert  cites. 

But  not  merely  do  I  dispute  the  adequacy  of  the  causes  enumerated  by 
the  authors  whose  names  I  have  given  ;  I  must  respectfully  question  the 
greater  prevalence,  as  a  rule,  of  a  particular  diathesis  among  the  sufferers 
from  obstinate  gonorrhoea,  and  expressly  state,  as  the  outcome  of  my  ob- 
servations, that  any  such  constitutional  tendency,  so  far  as  it  exists  at  all, 
may  be  seen  quite  as  strongly  developed  among  those  who  throw  off  the 
disease  quickly  enough.  Indeed  I  cannot  in  any  way  accept  the  conclusions 
arrived  at  by  these  gentlemen.  While  solicitous  to  avoid  saying  a  word 
that  might  give  offence,  I  am  compelled  to  remark,  that  the  principle  from 
which  they  start  is  essentially  vicious,  and  that  their  views  seem  to  me  rather 
moulded  in  conformity  with  traditions  long  current,  than  upon  exact  sta- 
tistical proof,  and  in  order  to  probe  the  question  thoroughly,  I  will  select 
two  or  three  of  the  factors  and  examine  their  operation. 

And  first  as  to  scrofula,  the  belief  in  which,  as  a  cause  of  inveteracy, 
is  one  of  those  vague  elastic  opinions  which,  while  they  have  the  advantage 
of  harmonizing  with  current  theories  and  modes  of  speaking,  possess  the 
still  greater  one  of  being  so  intangible  that  it  is  well-nigh  impossible  to 
deal  with  them  as  we  can  with  an  argument  reduced  to  a  definite  form. 
It  must  be  obvious  that  any  one  assailing  so  shapeless  a  doctrine  does  so 
at  a  great  disadvantage,  seeing  that  he  might  almost  as  easily  attack  a  phan- 
tom or  a  ghost.  Men  may  go  on  repeating  such  assertions  in  proportion 
as  books  are  multiplied,  till  what  was  at  first  a  loose  statement  becomes  a 
law  from  which  no  one  but  a  person  desirous  of  being  distinguished  for 
his  crotchets  would  venture  to  dissent ;  but  however  well  such  a  system 
might  suit  the  requirements  of  science,  it  would  not  bring  us  any  nearer 
the  truth,  which  is  quite  a  different  matter.  To  do  this,  we  must  first  of 
all  define  with  sufficient  strictness  what  is  really  meant  by  a  scrofulous 
diathesis  ;  and  then,  in  the  second  place,  ascertain  what  proportion  persons 


PATHOLOGY.  51 

so  affected  bear  to  the  entire  male  population.  Having  agreed  upon  the 
solution  of  the  former  point,  a  comparison  of  the  numbers  in  the  latter 
with  those  of  strumous  and  non-strumous  persons  suffering  under  gonor- 
rhoea, would  enable  us,  by  a  simple  sum  in  arithmetic,  to  get  at  the  facts  of 
the  case.  But,  to  begin,  difficulties  beset  the  question  of  definition.  If, 
as  is  pretty  clearly  the  opinion  of  some  medical  men,  inveteracy  is  in  itself, 
even  when  all  other  signs  are  absent,  to  be  looked  upon  as  decisive  testi- 
mony that  the  patient  is  of  this  temperament,  I  give  up  the  point.  There 
is  no  arguing  against  such  a  faith.  It  is  weighing  the  wind  and  counting 
the  sands  to  spend  time  upon  a  creed  like  this.  If  the  term  be  narrowed 
to  those  cases  in  which  we  find  the  accepted  and  unmistakable  marks  of 
scrofula  I  can  meet  it,  and  I  say  at  once  that  it  does  not  in  any  way  har- 
monize with  my  experience  to  find  inveteracy  associated  with  visible  signs 
of  struma.  Considering  that  struma  is  by  no  means  such  a  very  rare  disor- 
der, it  is  not  to  be  wondered  at  if  we  occasionally  see  gonorrhoeal  patients 
suffering  from  it.  A  scrofulous  person  exposes  himself  to  infection  the 
same  as  a  healthy  man  does,  and  pays  the  same  penalty. 

Many  years  ago,  in  some  remarks  on  this  question,  I  stated  that  I  had 
entirely  failed  to  connect  inveteracy  with  scrofula.  Since  then  I  have 
seen  a  pretty  large  number  of  obstinate  gleets,  and  have  rarely,  on  a  single 
occasion,  omitted  to  question  the  patient  carefully  as  to  the  possible  rea- 
sons for  the  persistence  of  his  complaint,  without,  except  in  the  instances  to 
be  presently  mentioned,  finding  evidence  of  the  strumous  diathesis.  I  never 
could  trace  anything  of  the  kind.  One  patient,  who  was  also  the  subject 
of  abscess  in  the  perineum,  had,  in  early  life,  been  afflicted  with  scrofu- 
lous ophthalmia  of  the  eyelids.  The  patient,  whose  rheumatic  affection 
was  complicated  with  inflammation  of  the  conjunctiva,  was  described  by 
Ms  medical  attendant  as  having  a  scrofulous  disposition  ;  but  the  opinion 
seemed  to  be  based  on  the  fact  that  the  ophthalmia  continued  to  resist  the 
treatment  employed,  and  that  the  patient  was  thin  and  pale.  All  the 
others  seemed  quite  as  healthy  as  the  average  of  men,  and  presented  every 
variety  of  temperament,  nor  was  there  a  single  sign  by  which  the  presence 
of  scrofula  could  be  recognized.  The  patient  spoken  of  later  on  as  having 
had  gleet  nearly  thirteen  years  was  a  remarkably  tall,  straight-limbed,  well- 
made  man,  with  a  mixture  of  red  and  brown  in  his  face  that  betokened 
the  best  of  health.  One  man  who  had  had  gleet  twelve  years  was  a  power- 
ful person  quite  six  feet  high.  A  patient,  with  prostatic  gleet  of  more 
than  twenty  years'  standing,  was  a  compact,  square-set  man,  wearing  every 
appearance  of  health  and  strength.  One  gentleman,  a  famous  runner,  also 
a  picture  of  health,  always  had  gonorrhcea,  when  he  was  unlucky  enough 
to  contract  it,  in  a  most  obstinate  form.  Are  we  then,  with  such  facts  as 
these  before  us,  to  accept  the  creed  that  inveteracy  must  mean  scrofula  ? 

In  the  same  way  I  would  deal  with  rheumatism  and  gout.  I  suppose 
•we  should  scarcely  err  in  saying  that  two  persons  at  least  out  of  five  suffer 


52  ON    GONOKKHCEA. 

more  or  less  from  rheumatism,  and  in  that  case  we  cannot  be  surprised  at 
finding  forty  patients  out  of  every  hundred  to  be  rheumatic.  If  the  first 
part  of  the  calculation  be  erroneous,  that  only  proves  more  strongly  the 
need  of  such  a  preliminary  inquiry  as  I  have  just  hinted  at.  As  to  gout, 
I  could  not  make  out  anything  to  my  satisfaction.  In  the  obstinate  case 
of  prostatic  gleet  spoken  of  as  lasting  more  than  twenty  years,  the  patient 
said  there  was  a  history  of  gout  in  the  family  ;  but  I  suppose  half  the  edu- 
cated people  in  England  might  say  the  same  thing  ;  and  I  know  that  I 
have  cured,  and  very  easily  too,  patients  suffering  under  gonorrhoea  and 
gleet  who  did  say  the  same  thing,  as  I  have  done  with  patients  not  only 
liable  to  rheumatism,  but  actually  rheumatic  at  the  time  they  contracted 
the  affection.  On  one  occasion  I  treated,  for  bad  urethra!  discharge,  a 
patient  whom  I  had  not  long  before  injected  six  times  with  morphia  by 
means  of  the  hypodermic  syringe  for  severe  rheumatism.  Yet  his  case  did 
very  well  and  showed  no  signs  of  obstinacy.  A  medical  man,  who  con- 
sulted me  for  a  long  standing  gleet,  unhesitatingly  put  it  down  to  his  father 
having  gout ;  but  it  seemed  to  me  that  if  such  were  the  case,  then  every 
son  of  a  gouty  father,  if  he  catch  gonorrhoea,  ought  to  have  gleet  in  a  re- 
bellious form,  which  does  not  happen.  Subsequently  this  patient  had 
very  bad  rheumatism  for  three  or  four  years,  and  then  I  wondered  which 
of  the  two  agents  was  now  to  be  blamed. 

As  to  temperament,  I  have  already  said  that  the  patients  laboring 
under  rebellious  gleet  presented  every  variety  of  it,  and  having  at  least 
twice  previously  given  my  reasons  for  distrusting  the  coarse  formulae  by 
which  its  varieties  are  to  be  distinguished,  I  trust  to  stand  excused  for  not 
repeating  them  here.  Such  a  method  of  parcelling  mankind  out  into  sec- 
tions may  have  its  advantages.  For  my  part,  I  at  once  confess  that  I  have 
never  been  able  to  see  them,  any  more  than  I  have  the  bearing  of  tempera- 
ment upon  the  enigma  we  have  been  discussing. 

Supposing  any  one  of  the  theories  I  have  been  enumerating  were  cor- 
rect, how  are  we,  by  means  of  it,  to  explain  the  varying  severity  of  gon- 
orrhoea at  different  times  in  the  same  person  ?  what  light  does  it  cast  upon 
the  problem  of  one  attack  of  the  disease  being  more  obstinate  than  another 
in  the  same  individual ;  of  the  second  being  worse  than  the  first,  or  the 
third  worse  than  the  second  ?  Are  we  to  assume  that,  on  these  less  fa- 
vorable occasions  the  diathesis  is  in  the  ascendant,  and  that  its  malignant 
influence,  after  a  lull,  is  again  permeating  the  patient's  frame  ?  And  if  a 
diathesis  be  the  cause  of  inveteracy,  on  what  principle  are  we  to  account 
for  the  peculiar  mildness  gonorrhoea  displays  through  every  successive 
attack  in  some  persons ;  on  that  of  such  favored  mortals  having  an  anti- 
strumous  diathesis  ?  The  reader  may  think  such  a  question  frivolous,  but 
I  put  it  with  no  such  meaning  attached  to  it.  If  there  be  any  truth  in  the 
theory  that  obstinacy  is  due  to  diathesis,  then  marked  exemption  from 
obstinacy  must  mean  marked  exemption  from  that  diathesis.  If  there  be 


PATHOLOGY.  53 

any  foundation  for  the  theory  it  merits  examination,  but  for  an  examina- 
tion to  be  of  any  value  it  must  embrace  both  sides  of  the  question. 

To  all  objections  of  this  nature  the  constant  reply  is,  that  some  expla- 
nation must  be  suggested,  and  that  even  a  very  erroneous  or  fanciful 
theory  has  sometimes  prompted  men  to  further  inquiry,  and  thus  opened 
the  way  to  truth.  I  must  entirely  dissent  from  such  a  doctrine,  preferring 
to  admit  that  I  am  only  stumbling  blindfold  through  a  maze  of  conjecture, 
and  have  not  reached  even  the  threshold  of  inquiry  ;  and  doubting  very 
much  whether  an  erroneous  hypothesis  ever  yet  assisted  in  the  discovery 
of  a  truth  which  men  would  not  have  found  out  equally  well  without  it 


CHAPTER  ni. 

TREATMENT. 

Variety  of  Remedies  Recommended. — Gonorrhoea  has  been  successfully 
treated  with  purgatives  and  diuretics,  corroboratives,1  astringents  and 
laxatives,  demulcents  and  alexipharmics,  mercury  and  iodine,  acids a  and 
alkalies,  anaesthetics,3  tonics,4  specifics,  and  treatment  on  general  princi- 
ples ;  so  that  the  puzzle  must  be,  not  to  find  out  what  will  cure  it,  but 
what  there  is  in  the  wide  domain  of  therapeutics  that  does  not  possess 
this  power.  An  old  author  complains  that  the  specific  for  this  disease  had 
not  yet  been  found ;  had  he  lived  in  the  present  day,  he  might  have  la- 
mented that  there  were  rather  too  many,  always  supposing  we  are  to  put 
faith  in  what  we  are  told  about  some  of  the  medicines  recommended.  As 
to  injections,  the  variety  is  quite  as  great,  at  least  eighty  different  sub- 
stances and  combinations  having  been  recommended  for  this  purpose 
within  the  last  few  years.  External  applications  do  not  offer  the  same 
scope  for  diversity,  yet  it  can  scarcely  be  said  that  they  have  lagged  much  in 
the  rear.  If  their  narrow  bounds  do  not  admit  of  much  choice,  they  leave 
the  way  open  for  sufficient  difference  of  opinion  as  to  the  mode  in  which 
they  are  to  be  applied.  Maceration  for  five  or  six  hours  in  a  hot  bath  has 
been  strongly  recommended,  while  Ricord  and  some  of  the  French  surgeons 
tell  us  that  the  hot  bath,  even  in  the  usual  form,  is  highly  calculated  to  de- 
velop gonorrhoea  ;  authors  have  even  gone  so  far  as  to  interdict  it.  Some 
practitioners  apply  evaporating  lotions  to  the  penis  for  the  purpose  of  re- 
ducing the  inflammation,  perhaps  it  would  be  more  correct  to  say,  in  the  hope 
of  doing  so  ;  others  have  resorted  to  ice  with  the  same  view.  Men  with 
views  opposed  to  this  treatment  sedulously  caution  the  patient  to  avoid 
anything  in  the  shape  of  cold  getting  to  the  part,  or  even  sanction  the  use 
of  india-rubber  bags,  which,  though  they  prevent  the  linen  from  being 
stained,  keep  the  organ  hotter  than  the  bath  would  do.  Swediaur  carried 
prudence  so  far  as  to  deprecate  making  water  in  the  street  when  there 
was  a  cold  wind  blowing. 

It  is  gratifying  to  find  that,  with  all  this  warfare  of  opinion,  we  are 

'Swediaur:  Op.  citat.,  p.  65. 

s  Essays  on  the  Venereal  Disease.    By  William  Blair.     Pp.  36,  72,  etc.     1798. 

JArchiv  fur  Dermatologie,  B.  S.,  593.  4 Lancet,  vol.  ii.,  p.  428.     1870. 


TREATMENT.  55 

really  making  progress,  and  that  we  cannot  only  cure  the  disease  in  many 
different  ways,  but  cure  it  with  a  rapidity  which  leaves  the  feats  of  past 
days,  and  the  most  audacious  assurances  of  quackery,  alike  in  the  back- 
ground. Our  fore-fathers  were  content  with  removing  gonorrhoea  in  a 
week  or  two,  and  the  boldest  charlatan,  who  undertook  the  same  task,  re- 
quired a  few  days  to  do  it  in.  But  now  we  have  remedies  which  cure  the 
disease  in  nearly  ninety  per  cent,  of  the  cases  at  a  single  sitting,  leaving 
the  impartial  reader  quite  at  a  loss  to  know  why  we  ever  meet  with  bad 
gonorrhoea  at  all,  and  why  every  patient  who  may  happen  to  catch  it  does 
not  insist  upon  being  treated  according  to  one  of  these  speedy  and  infal- 
lible methods. 

Continuance  of  the  same  Fundamental  Principles  of  Treatment. — What 
may,  I  think,  be  called  the  fundamental  principles  of  treatment,  of  that 
treatment  which  is  most  largely  adopted  in  each  successive  age,  have,  ex- 
cepting the  use  of  injections,  changed  less  amid  ail  this  disparity  of 
opinion  during  the  last  century  or  two  than  might  be  supposed.  The 
handling  of  the  subject  is  more  scientific,  but  possibly  not  so  much  more 
likely  to  promote  success,  the  grand  test  after  all.  The  vague  and  elastic 
rules  of  treatment  laid  down  in  text-books  and  dictionaries,  the  want  of 
tangible  proof  as  to  the  proportion  between  cure  and  failure,  mean,  in 
plain  words,  old  results  in  a  more  modern  dress  and  phraseology. 

Judging  from  what  I  see  and  hear,  treatment  is  rather  regulated  by 
the  impression  some  striking  case  of  cure  or  failure  has  made  at  the  out- 
set of  the  surgeon's  career,  or  by  the  views  some  favorite  teacher  or  emi- 
nent specialist  may  have  inculcated,  than  by  conclusions  drawn  from  long 
and  carefully  watching  the  action  of  medicines.  If  this  be  the  case,  then 
I  think  matters  have  gone  on  long  enough  in  this  way  to  excuse  me  for 
saying,  that  there  is  no  cure  for  the  uncertainty  in  the  present  state  of 
things,  and  that  the  remedy  would  be  a  more  full  study  of  the  therapeu- 
tics of  the  complaint,  even  supposing  we  had  for  this  purpose  to  exclude 
many  interesting  points  in  etiology  and  pathology,  coupled  with  a  system 
of  observation  on  a  simple,  uniform  plan,  ivhich  dealt  only  with  certainties, 
which  admitted  no  case  as  cured  or  uncured  unless  the  surgeon  saw  it  for  him- 
self, and  where  the  history  comprehended  the  beginning  and  ending  of  the 
disease.  But  of  such  a  step  I  have  no  hope.  The  tendency  of  the  age  is 
to  exalt  scientific  experiment,  however  useless  it  may  be,  and  to  2^ass  by  the 
teaching  of  experience,  as  if  to  gather  these  did  not  demand  as  much  toil 
and  self-sacrifice  as  the  other.  One  consequence  of  this  is  that  time  is 
spent  on  experiments  which  settle  nothing,  while  we  cannot  get  at  data  for 
establishing  rules  of  treatment.  In  support  of  this  statement  let  me  ask 
the  reader  to  take  any  of  the  more  recent  works  on  venereal  diseases  and 
to  compare  what  is  said  on  the  management  of  gonorrhoea,  especially  the 
part  contributed  by  the  author,  that  is  to  say  what  is  new,  with  the  bulk 
of  the  section  on  this  disease.  I  think  he  will  admit  that  I  have  not  over- 


56  ON    GONORRH(EA. 

colored  matters  in  saying,  that  the  treatment  is  made  quite  a  subordinate 
question  to  those  of  causation  and  pathology. 

The  point  appeal's  to  me  of  so  much  importance,  that  at  the  risk  of  ap- 
pearing ever  so  tedious,  I  will  take  an  instance  of  the  vagueness  of  the 
rules  laid  down  by  our  teachers.  I  select  it  from  the  writings  of  an  emi- 
nent surgeon,  the  late  Sir  William  Fergusson.  He  tells  us  that  gonorrhoea 
must  be  treated  on  general  principles,  and  that,  though  it  must  be  admitted 
that  the  disease  is  now  and  then  cut  short  by  an  astringent  or  caustic  so- 
lution, it  is  more  the  result  of  chance  than  judgment ;  and  in  many  instan- 
ces, where  it  has  been  supposed  that  this  was  the  case,  gonorrhoea  has  in 
reality  not  been  present. 

This  is  all  en  regie  ;  but  what  a  picture  of  uncertainty,  what  a  maze  of 
doubt  it  reveals !  How  much  better  it  would  be  to  say  at  once  to  the 
pupils :  "  Gentlemen,  you  must  first  of  all  check  the  inflammation  by  an- 
tiphlogistics — not  that  I  ever  convinced  myself  by  experiment  that  these 
remedies  have  any  power  to  effect  this  purpose,  but  because  so  many  ex- 
cellent authorities  have  insisted  upon  their  efficacy.  Perhaps  they  knew 
no  more  about  the  matter  than  you  or  I  do  ;  however,  that  is  no  business 
of  ours  ;  the  orthodox  plan  is  to  pay  them  due  respect,  and  quote  them  on 
all  fitting  occasions.  Then  if  you  think  it  right,  and  I  have  no  rule  to  offer 
you,  specifics  may  be  given  ;  they  may  cure  the  case,  or,  which  is  just  as 
likely,  do  no  good.  I  use  the  phrase  general  principles  much  as  it  has  al- 
ways been  used,  without  attaching  any  very  distinct  meaning  to  it ;  and 
must  admit  that,  if  pressed  for  a  strict  definition,  I  might  feel  rather  em- 
barrassed. As  to  injections,  I  cannot  say  that  I  have  myself  seen  an  in- 
stance in  which  stricture,  abscess,  or  swelled  testicle  resulted  from  them 
when  properly  given,  even  in  the  acute  stage  ;  but  then  the  authorities  I 
have  consulted  very  naturally  dread  the  result  of  imprudent  haste.  If 
these  remedies  fail,  you  must  use  your  own  discretion  about  trying  others. 
When  you  have  exhausted  your  stock,  send  the  patient  to  the  sea-side,  or 
anywhere  else,  so  long  as  you  only  get  rid  of  him.  Do  not  worry  your- 
selves about  failure.  You  have  done  everything  sanctioned  by  the  legiti- 
mate practice  of  surgery,  and  have  therefore  nothing  to  reproach  yourselves 
with." 

I  am  continually  asked  if  I  have  tried  some  new  remedy — the  specific 
of  the  day — to  which  I  simply  reply,  that  I  am  very  glad  to  try.  anything 
recommended  upon  good  grounds,  anything  that  holds  out  the  hope  of 
exhibiting  greater  curative  power  than  is  possessed  by  the  remedies  I  know  ; 
but  that  I  entirely  object  to  wasting  the  patient's  time  and  my  own  ;  to 
running  the  risk  of  causing  him  unnecessary  suffering,  and  reaping  for 
myself  only  discredit  and  vexation,  for  the  purpose  of  testing  the  virtues 
of  any  novelty,  unless  these  are  supported  by  the  history  of  a  sufficient 
number  of  well-observed  cases. 

There  may  be  too  much  of  a  good  thing,  and  I  think  we  have  had  too 


TKEATMENT.  57 

much  in  the  shape  of  novelties  for  many  years  past ;  merely  adding  to  the 
list  of  remedies,  already  long  enough,  many  of  which  are  just  as  useful  as 
a  "beane  putte  into  ye  harte  of  a  black  cat,"  can  do  no  good  whatever. 
Any  simple  remedy  and  mild  injection  will  cure  most  cases  of  gonorrhoea. 
One  or  two  of  these  may  be  found  every  year  in  some  of  our  medical 
repertories,  and  a  reader,  tempted  to  go  into  the  literature  of  this  subject, 
might  be  interested  and  amused  to  see  how  many  are  periodically  intro- 
duced as  though  they  had  never  been  heard  of  before.  Those  fond 
of  new  modes  of  treatment  are  therefore  able  to  gratify  their  taste  ;  but 
unless  it  could  be  shown  that  the  newly  discovered  specific  really  cures 
more  cases  out  of  a  given  number  than  the  remedies  every  person  is  fami- 
liar with,  or  is  specially  adapted  to  a  particular  class  of  cases  which  can  be 
diagnosed  at  the  outset,  its  introduction  would  merely  add  to  the  existing 
confusion.  I  therefore  propose  to  examine  only  those  which  seem  excep- 
tionally entitled  to  notice. 

It  is  perhaps  this  incessant  supply  of  novelties  that  has  rendered  men 
so  inattentive  to  the  few  improvements  which  have  been  suggested  in  the 
treatment  of  gonorrhoea,  such  as  the  addition  of  long  tubes  to  syringes, 
the  use  of  fresh-ground  cubebs  suggested  by  Mr.  Norman,1  and  the  sepa- 
ration of  the  effete  and  nauseous  parts  of  copaiba  from  the  more  useful 
constituents  by  Mr.  Thorn.2  The  discoveries  of  Mr.  Norman  and  Mr. 
Thorn  may  have  been  useless.  I  have  had  no  opportunity  of  making  such 
observations  as  to  enable  me  to  form  an  opinion,  and  therefore  offer  none. 
What  I  have  to  deal  with  is  the  total  neglect  shown  by  the  medical  public 
on  both  occasions.  Judging  as  well  as  I  can,  I  should  say  it  is  much  more 
likely  that  they  were  of  value  ;  there  was  quite  evidence  enough  in  their 
favor  to  have  recommended  them  to  the  notice  of  medical  men.  Yet 
they  were  honored  with  no  more  attention  than  if  they  had  belonged  to 
the  class  of  trashy  and  ephemeral  papers  on  such  topics  so  often  seen  in 
our  journals.  Mr.  Thorn's  preparation  was  carefully  tested  by  the  late  Mr. 
Tyrrell,  and  found  most  efficacious.  Yet  his  work  was  received  with  so 
much  coldness,  that  he  soon  after  threw  up  the  subject  in  disgust,  and  left 
England  in  consequence. 

It  was  represented  to  me  that  a  work  of  this  kind  would  be  incomplete 
without  a  history  of  the  treatment  of  gonorrhoea.  The  suggestion  is  no 
doubt  founded  on  a  correct  view  of  the  case,  but  on  going  into  the  litera- 
ture of  the  subject,  I  found  that  to  execute  such  a  plan  thoroughly  would 
carry  me  too  far.  Besides,  after  all,  a  history  of  this  nature  would  be 
more  amusing  than  instructive.  It  might  be  made  to  present  a  curious 
picture  of  bygone  times,  but  it  would  convey  little  real  information  ;  for 
it  must  necessarily  be  a  narrative  of  the  same  principles  of.  treatment,  re- 

1  Lancet,  vol,  i.,  p.  631.     1856. 

2  On  the  Treatment  of  Gonorrhoea  by  a  new  Preparation  of  the  Balsam  of  Copaiba. 
1827. 


58  ON    GONORRHOEA. 

curring  again  and  again  under  almost  countless  changes  of  form  and  au* 
thorship. 

The  reader  was  probably  startled  by  an  observation  in  one  of  the  pre- 
ceding paragraphs,  viz.,  that  treatment  had  not  altered  so  much  in  the  last 
century  or  two  as  might  have  been  expected  ;  yet  there  seems  no  other 
conclusion  to  arrive  at.  It  is  true  the  outward  form,  the  husk,  so  to  say, 
has  somewhat  changed  ;  prescriptions  are  less  complicated,  medicines  are 
given  in  milder  doses  and  rather  less  nauseous  forms.  The  language  of 
medicine  is  no  longer  what  it  was,  and  old  terms  and  old  formulae  have 
died  out,  while  new  ones  have  sprung  up  ;  but  beneath  all  this  the  essence 
of  both  practice  and  theory  has  remained  much  the  same.  The  discrepan- 
cies of  to-day  are  but  amplifications  of  those  which  prevailed  when  Howard 
commented  on  gonorrhoea  "  having  been  so  often  cured  in  a  great  variety 
of  different  ways."  In  this  instance  we  might  say  of  medicine  as  of  lan- 
guage, that  while  the  outer  semblance  is  in  a  state  of  perpetual  mutation, 
its  radical  structure  undergoes  but  little  change. 

With  the  reader's  permission,  I  will  endeavor  to  illustrate  this  by 
means  of  a  few  instances,  beginning  a  little  later  than  the  middle  of  the 
seventeenth  century  with  the  famous  Sydenham. 

Sydenham's  Treatment. — Although  this  great  man  separated  the  treat- 
ment of  "  gonorrhoea  virulenta "  from  that  of  venereal  disease,  he  never 
discovered  that  there  was  a  fundamental  distinction  between  the  two.  He 
describes  gonorrhoea  as  beginning  with  "  an  uncommon  pain  in  the  parts  of 
generation  and  a  kind  of  rotation  of  the  testicles,"  while  in  those  who  have 
not  been  circumcised,  "  a  spot  not  unlike  the  measles  appears  on  the  glans  ;" 
then  the  discharge  from  the  urethra  comes  on,  and  "  when  this  disease  is 
more  virulent  and  degenerated  into  the  pox,"  "this  matter  becomes  green, 
and  is  mixed  with  a  watery  humor  streaked  with  blood."  The  description 
is  anything  but  full  and  clear  ;  indeed,  were  it  not  by  so  eminent  a  person, 
I  should  say  it  was  as  bad  as  it  could  be. 

The  first  thing  that  strikes  us  in  Sydenham's  treatment  is  a  feeling  of 
astonishment  that  he  did  not  kill  a  good  many  of  his  patients,  or  give  them 
bleeding  piles,  tenesmus,  and  excoriation  of  the  anus.  Possibly,  like  How- 
ard,' he  looked  upon  the  occurrence  of  piles  as  rather  a  favorable  inci- 
dent, calculated  to  "  draw  off  irritation  from  the  urethra."  He  directs  3 
"  three  drachms  of  cochia  (colocynth)  pill,  a  drachm  of  extract  of  rudius, 
half  a  drachm  of  resin  of  jalap,  and  half  a  drachm  of  resin  of  scammony," 
with  "sufficient  of  opobalsamum  "  3  to  make  them  into  a  mass.  Of  this 


1  Practical  Observations  on  the  Natural  History  and  Cure  of  the  Venereal  Disease, 
vol.  iii.,  p.  26.  1787. 

JThe  Works  of  "Thomas  Sydenham,  vol.  ii.,  p.  453.     1788. 

3  Balm  of  Gilead,  procured  from  the  Balsamodendron  Gileadense,  one  of  the  Terebin- 
thaceae.  Physiological  effects  similar  to  those  of  copaiba  and  the  turpentines.  Disused 
in  Europe. 


TREATMENT.  59 

mass  two  scruples,  in  the  form  of  four  pills,  were  to  be  taken  every  morning, 
till  the  running  had  grown  considerably  paler  and  the  scalding  abated  ;  I 
fancy  the  patient  must  often  have  grown  paler  under  such  handling.  Those 
who  were  "  hard  to  purge,"  and  I  should  say  they  must  have  been  decidedly 
"  hard  "  when  their  intestines  resisted  snch  a  stimulus,  were  directed  to 
take,  in  addition,  his  "purging  potion  "  now  and  then,  with  two  drachms 
of  the  syrup  of  buckthorn  and  the  same  ( quantity  of  the  electuary  of  the 
juice  of  roses.  If  the  cure  went  on  slowly,  eight  grains  of  "  turbith  min- 
eral "  were  given  every  five  days,  or  half  a  drachm  of  "  pills  of  two  princi- 
pal ingredients  "  and  a  scruple  of  "  sweet  mercury  "  made  into  a  mass  with 
opobalsamum ;  not  a  bad  dose.  In  addition  to  these  remedies  he  gave 
opobalsamum  in  doses  of  twenty-five  drops  every  night,  or  "  the  quantity 
of  a  hazle-nut  of  cypress  turpentine. "  Sometimes  he  gave  every  second 
day  half  a  drachm  "  of  the  pills  of  two  principal  ingredients,"  and  three 
drops  of  opobalsamum.  He  also  gave  half  an  ounce  of  Venice  turpentine 
occasionally  in  a  clyster.  The  patient  was  also  to  be  "  blooded  "  once  or 
twice  toward  the  middle  of  the  course :  rather  a  bold  step,  for  generally 
speaking  men  at  that  time  dreaded  the  idea  of  venesection  and  antiphlogis- 
tics,  for  fear  of  inducing  absorption  of  the  peccant  matter. 

Sydenham  used  also  to  order  his  patients  a  "  cooling  or  thickening 
diet,"  one  item  of  which  was  "  emulsions  of  the  four  greater  cold  seeds." 
For  swellings  of  the  penis  or  testicle  he  advised  elaborate  fomentations 
of  marshmallow,  white  lilies,  mullein,  elder,  camomile,  melilot,  flax  and 
fennel  seeds,  for  the  particulars  of  which  I  must  refer  the  reader  to  his 
works. 

Supposing  the  drugs  used  in  Sydenham 's  time  were  pure,  we  must  be- 
lieve that  his  patients  had  greater  powers  of  endurance,  or  more  faith  in 
their  physician,  than  those  of  the  nineteenth  century.  A  scruple  or  half- 
drachm  dose  of  such  pills  as  he  prescribes  would  produce  a  rather  startling 
effect  on  a  patient  in  this  degenerate  age,  and  nowadays  the  "  turbith  min- 
eral ".(the  yellow  subsulphate  of  mercury)  causes  vomiting  of  the  most  vio- 
lent kind  in  half  the  quantity  prescribed  by  Sydenham. 

I  now  proceed  to  examine  the  practice  of  a  somewhat  later  date,  select- 
ing as  specimens  Moyle,  Marten,  and  Turner. 

Moyle's  Treatmyit. — Moyle  directs '  his  readers  to  purge  well  for  the 
running,  but  not  to  give  anything  to  stop  it,  "lest  it  mingle  with  the 
Blood,  and  so  become  a  confirm'd  Pox ;"  and  not  to  bleed,  for  the  revul- 
sion thereby  occasioned  "  makes  for  the  malign  Atoms  or  Fumes  to  ascend 
from  the  Pocky  ferment  in  the  Inferiour  parts  and  teints  the  blood  in  the 
Superiour."  His  purgative  consists  of  pil.  rudii  3j.  ;  resin,  jalap,  gr.  v.  ; 
$  dulc.  gr.  x.  ;  every  second  day  for  five  times.  The  patient  is  to  "  for- 
bear strong  liquors,"  and  when  "the  Malignity  is  carried  off"  he  is  to  take 


1  The  Sea-Chirurgion.     By  John  Moyle,  senior,  one  of  Her  Majesty's  Ancienl  Sea- 
Chirurgions.     1702. 


60  ON.   GONORRHOEA. 

two  drachms  of  cypress  turpentine  in  an  emulsion  night  and  morning  "  for 
five  times  going."  This  generally  cured  the  patient,  but  if  a  "Gleeting" 
remained  he  was  to  purge  again. 

Marten's  Treatment. — Marten  belonged  to  quite  as  rough  a  school  as 
Moyle,  but  one  evincing  a  much  lower  grade  of  professional  feeling  ;  for 
the  old  "  sea-chirurgion  "  is  honest  and  open,  whereas  Marten  kept  his 
remedies  to  a  great  extent  secret.  He  is  communicative  enough  about 
some  of  his  affairs,  snch  as  the  presents  sent  to  him  by  grateful  patients, 
the  premium  which  he  received  with  his  apprentice,  the  price  for  which 
he  sold  his  "  general  Business,"  or  his  benevolence  in  curing  the  poor 
gratis,1  but  the  reader  is  left  in  the  dark  as  to  his  real  treatment.  He 
says,  with  an  air  of  innocence  which  might  well  call  forth  a  smile,  in  speak- 
ing of  some  infallible  liquor,  "  But  what  this  Liquor  is  or  how  it  is  to  be 
prepared,  the  Reader,  I  say,  must  pardon  me  at  this  time  that  I  do  not 
reveal."  Indeed,  the  surgeon  of  that  day,  albeit  he  might  boast  of  belong- 
ing to  the  "  Worshipful  Company  of  Barber  Chirurgions,"  or  stood  at  the 
top  of  the  tree  in  some  specialty,  was  often  little  better  than  a  mountebank 
or  fortune-teller.  The  most  arrant  empiric  was  much  on  a  par  with  his 
diplomaed  rival.  A  regiment  of  the  first  class  was  handed  over  to  one 
charlatan  ;  the  piUs  of  another  were  sold  at  a  guinea  a  dozen  ;  nobility  and 
even  royalty  availed  themselves  of  the  vaunted  skill  of  a  third ;  and  the 
public  here,  at  any  rate,  openly  sympathized  with  any  man  who  professed 
to  wage  war  against  chartered  monopoly.  Sir  William  Read,  the  queen's 
oculist,  had  been  a  mountebank.2  He  was  so  ignorant  that  he  could 
hardly  read,3  and  even  after  his  appointment  continued  to  sell  nostrums. 
Dr.  Thomas  Saffold,  spoken  of  in  the  Taller  as  "my  ingenious  friend,"  had 
been  a  weaver  and  a  fortune-teller  before  he  became  undergraduate  in 
physic.  The  infamous  quack,  St.  Andre,  the  associate  of  the  notorious 
Mary  Toft,  was,  in  1726,  chirurgeon  to  the  king's  household. 

To  quote  almost  literally  from  Marten,  when  a  man,  a  Mohawk  for  in- 
stance, or  a  "looser  sort  of  Spark,"  had  "conversed  with  a  Slut,"  and  had 
caught  "a  pocky  Running,"  with  "a  Stupidity  of  the  Yard,"  he  came  to  the 
conclusion  that  he  was  "  inflicted  with  the  Pox,"  and  sent  for  his  medical 
man,  who  forthwith  came  in  a  mighty  periwig,  and  after  a  preliminary  rail- 
ing at  the  "Quacking  Empirical!  Fellow"  in  the  "Darl»  Entry,"  or  at  the 
sign  of  "  the  Hand  and  Urinal,"  or  the  "Frying  Pan  ;"  diversified,  it  may 
be,  with  a  warning  narrative  of  some  "  Gentleman  who  was  blowed  up  to 
the  Planets,"  owing  to  his  having  taken  too  strong  a  dose  from  one  of  these 
worthies,  he  proceeded  to  strike  a  bargain  with  the  patient  as  to  his  terms 
for  effecting  a  cure,  and  this  done  he  set  to  work. 


1  "  The  poor  I  cure  gratis,  no  less  I  believe  than  to  the  value  of  £100  per  Ann. ,  dis- 
charging both  to  Poor  and  Rich,  as  near  as  I  can,  an  honest  conscience." — A  True  and 
Succinct  Account  of  the  Venereal  Disease.  By  John  Marten,  Chirurgion.  1700. 

»  The  Tatler,  vol.  i.,  p.  84.    1797.  *  Ibid.,  vol.  iv.,  p.  218. 


TREATMENT.  61 

Marten's  practice  consisted  "in  cleansing  and  destroying  the  Malig- 
nity," in  giving  "  gentle  Specificks,  appropriated  suitable  to  the  Distemper." 
For  "  Scalding  of  Urine  "  he  gave  "  two  or  three  quarts  a  day  of  proper 
Liquors,"  which  "radically  extinguished  and  destroyed  the  very  Seed  of  the 
Disease."  He  had  a  great  horror  of  stopping  the  discharge  by  "  Emplas- 
tics  and  Restringents,"  lest  by  using  them  "  the  Venereal  Malignity  abscond- 
ing itself  in  the  Liminary  or  Spermatic  Parts,"  might  degenerate  into  "a 
radicated  and  ill-contrived  Pox,"  or  "  a  Tumor  Humoralis  happen  upon  the 
testicle."  But  how  he  effected  all  this  I  leave  to  be  explained  by  those  who 
can  gather  anything  definite  from  his  book. 

Has  the  reader  ever  heard  this  theory  about  purging  off  the  malignity, 
not  stopping  a  discharge  lest  it  might  be  absorbed,  or  be  thrown  into  the 
system,  or  something  of  that  kind,  repeated  under  another  form  in  the 
present  day  ? — because  if  not,  I  have,  and  very  frequently  too. 

Turner's  Treatment. — Turner  clearly  separates :  gonorrhoea  from  syphilis 
in  so  far,  that  while  he  admits  the  possibility  of  a  neglected  or  badly  treated 
blennorrhagia  being  transmuted  into  syphilis,  he  carefully  points  out  that 
it  may  run,  or  rather  that  it  naturally  runs,  its  course  without  anything  of 
the  kind  happening.  The  treatment  of  gonorrhoea  is  accordingly  kept  tol- 
erably distinct  from  that  of  the  more  serious  disease,  or,  as  he  quaintly 
terms  it,  "  the  second  Infection  called  the  Pox." 

His  treatment  consisted  of  purgatives  given  perseveringly  till  the  more 
severe  symptoms  had  passed  off,  or,  to  use  his  own  words,  till  "  the  Cacoch- 
ymy  was  discharged,"  and  "  the  Stillicidium  was  lessened  in  Quantity  and 
had  grown  better  conditioned."  He  began  with  "Ext.  rud.,"  "Pil.  coch. 
min."  or  "Pil.  ex  duobus,"  3j.  to  3  ss.  of  the  latter,  or,  if  the  patient  were 
strong,  3ij.  along  with  3ss.  gr.  xv.  or  3j.  of  calomel.  After  this  he  gave 
powdered  rhubarb  with  some  preparation  of  turpentine,  and  followed  these 
up  with  copaiba,  on  which  he  placed  great  reliance.  Injections  he  avoided, 
except  very  mild  ones,  such  as  barley-water,  "  a  small  solution  of  the  Troch. 
Alb.  Rhus  in  aq.,  Plantag.  vel.  Ros.,"  or  "  a  small  Aq.  Calcis  c.  Syr.  de  Ros. 
sice,  vel  Mel  Ros."  For  phimosis  and  paraphimosis  he  recommended  that 
"  the  Humour  should  be  revulsed  by  an  Emetick,"  and  that  "  a  good  dis- 
cutient  Fotus  should  be  apply 'd  to  breath  out  the  impacted  Humour." 
Scalding  he  tried  to  alleviate  with  sedatives,  such  as  poppy  and  hyoscyamus 
and  "  edulcorants,"  e.  g.,  gum  arabic  and  milk  of  almonds.  When  chordee 
was  present  he  added  five-grain  doses  of  sugar  of  lead  and  the  same  quan- 
tity of  camphor  for  painful  micturition.  His  remedies  for  orchitis  were  "  a 
suitable  Bag  Truss  "  and  warm  cataplasms,  at  the  same  time  directing  that 
"  all  Restringent  or  Balsamic  Medicines  be  entirely  forborn."  For  the  sym- 
pathetic bubo  of  gonorrhoea  he  had  no  separate  treatment. 

1  Syphilis  :  A  Practical  Dissertation  on  the  Venereal  Disease.  By  Daniel  Turner,  of 
the  College  of  Physicians.  1717.  This  work  contains,  in  accordance  with  a  good  old 
fashion,  a  well-executed  likeness  of  the  author. 


62  ON    GONORRHCEA. 

Turner  was  evidently  a  sound,  careful  physician.  He  held  that  the 
way  to  improve  treatment  and  gain  a  better  knowledge  of  disease  was  to 
study  symptoms  and  observe  the  action  of  medicines.  "  The  new  way  by 
Arithmetic,  Algebra,  and  Elementa  Mathematica  !  "  he  considered  only  fit 
to  amuse  young  heads,  and  fill  them  with  what  he  plainly  calls  "  gibber- 
ish." According  to  him  gonorrhoea,  like  syphilis,  arises  from  an  unknown 
infecting  property  in  the  discharge  of  the  person  who  communicates  it,  "a 
Poison  of  a  peculiar  Nature,  and  acting  upon  the  Blood  and  Humours  of 
humane  Bodies."  Treatment  he  therefore  thought  must  be,  for  the  time 
being,  empirical,  and  he  counsels  the  reader  to  "take  his  Indications 
chiefly,  if  not  solely,  a  juvantibus  et  Isedentibus." 

Cockburn' s  Treatment. — Cockburn  seems1 — for  he  words  his  opinions 
here  very  obscurely — to  have  used  "Purging,  Astringent  and  Healing 
Medicines,"  such  as  turpentine  with  lemon-juice  and  sugar,  opobalsamum, 
Peruvian  balsam  and  copaiba,  along  with  rhubarb,  acetate  of  lead,  pulp  of 
cassia,  syrup  of  marshmallow,  and  sal  prunella.  He  had  great  faith  in 
purgatives  and  injections,  though  he  believed  that  the  improper  use  of  the 
latter  might  bring  on  "  the  Lues."  He  held  that  diuretics  effected  a  "  mere 
washing  of  the  Urethra,"  and  were  apt  to  be  very  injurious  by  causing  too 
great  "  an  Afflux  of  Humours  to  the  stimulated  Part."  To  relieve  scalding, 
the  volatile  salt  of  amber,  sugar-candy  in  tincture  of  tea,  or  whey,  along 
with  crystal  mineral,  nitrate  of  potass  and  tragacanth,  remedies  perhaps  as 
useful  and  pleasant  as  most  of  those  used  nowadays  for  this  symptom ;  for 
"  Cording  of  the  Penis  "  cold  bathing  and  internally  warm  milk,  sugar  of 
lead,  white  lily  root,  etc.  He  treated  phimosis,  which  he  thought  only 
merited  the  title  when  the  "  Choaking  of  the  Prseputium  "  gave  pain,  with 
a  vast  variety  of  remedies,  such  as  bryony,  and  thought  the  method  which 
prevailed  in  his  day,  of  draining  the  water  from  the  foreskin  by  "  insinua- 
ting green  Gentian  Roots,  the  pith  of  the  Wayfaring  Tree,  or  a  bit  of 
Sponge  between  the  Glans  and  Foreskin  "  was  bad  ;  a  view  in  which  my 
readers  will  possibly  concur. 

Astruc's  Treatment. — We  now  come  to  the  practice  of  an  author  whose 
views  seem  to  have  been  pretty  extensively  adopted  in  England,  where  sur- 
gery had  been  getting  on  slowly ;  for  Mr.  Pott  tells  us,  that  when  he  be- 
gan his  studies,  a  little  before  the  time  that  Astruc's  writings  began  to  be 
known  here,  there  was  not,  with  the  exception  of  Cheselden,  Wiseman,  and 
Sharpe,  "an  English  writer  on  surgery  fit  to  be  read,"  and  that  no  lectures 
were  given  in  London  "  on  the  Materia  Medica,  Chymistry,  or  the  Practice 
of  Physick."  Perhaps  it  was  a  deep  sense  of  contrition  for  their  short- 
comings in  this  way  that  impelled  the  surgeons  of  that  day  often  to  weep 
disconsolately  at  the  bedside  of  their  patients !  Disgusting  as  such  an  ex- 

1  The  Symptoms,  etc.,  of  Gonorrhoea.  By  W.  Cockburn,  M.D.,  Fellow  of  the  R.S., 
etc.  1728. 


TREATMENT.  63 

hibition  must  seem  now,  it  appears  to  have  been  quite  a  common  occur- 
rence in  Mr.  Pott's  time,  for  we  are  told,  as  a  striking  instance  of  his  up- 
rightness, that  "  he  never  would  consent  to  whine  over  a  patient !  " 

Astruc's  general  plan  seems  '  to  have  been  in  the  first  stage  to  bleed, 
give  ptisans  of  cooling  plants,  such  as  chiccory,  wood-sorrel,  lettuce,  etc. 
When  the  bowels  were  to  be  moved  he  gave  the  ptisan  in  the  form  of  .a 
glyster,  with  a  drachm  or  two  of  "  Crystal  mineral  or  an  ounce  of  fresh 
pulp  of  Cassia."  He  poulticed  the  perineum  with  "  crumb  of  bread,  milk 
and  Saffron,"  and  injected  into  the  urethra  "  Saccharum  Saturni  in  Frog- 
spawn  water,"  or  "  Goat's  milk  diluted  with  a  decoction  of  Marsh  mallow." 
He  gave  "  Camphire  and  Saccharum  Saturnum  "  internally  "  to  ass  wage 
the  heat  of  the  parts,"  and  prescribed  a  "light  moist  diet,"  with  absence 
from  ah1  peppered  or  preserved  meats. 

In  the  second  stage  he  "  purged  gently  "  with  cassia,  or  gave  ten  or 
twelve  grains  of  jalap  or  "  Diagridion,"  possibly  an  old  name  for  scammony, 
or  a  scruple  of  calomel,  which  I  should  think  must  have  purged  very  gently 
indeed,  though  it  was  certainly  quite  a  common  dose  in  those  days.  This 
was  followed  up  by  mercurial  inunction. 

In  the  third  stage,  that  is  to  say  when  the  dysuria,  erections,  etc.,  had 
passed  off,  he  gave  "  Chio  Turpentine,"  powdered  rhubarb,  and  copaiba  or 
Canada  balsam  in  moderate  doses,  accompanied  by  a  host  of  other  reme- 
dies, among  which  we  find  nine  astringents,  such  as  catechu,  dragon's 
blood,  etc.,  to  be  taken  internally.  Mucous  gleet  he  treated  with  "  deter- 
sive" injections  of  decoction  of  bugloss,  geranium,  etc.,  mixed  with  solu- 
tion of  honey  of  roses. 

In  the  "oedematous  kind"  he  bled  less,  purged  repeatedly  and  freely, 
and  gave  a  sudorific  ptisan  of  guaiacum  and  sassafras  woods.  When  there 
was  much  phlegmon  he  ordered  frequent  bleeding,  with  diluting,  softening, 
and  anodyne  medicines. 

For  the  Venereal  tumour  of  the  testicles,  or  the  Venereal  Hernia  (or- 
chitis),  which  he  warns  his  readers  may  degenerate  into  schirrus,  sarcocele, 
or  cancer,  he  bled,  gave  aperients,  laid  aside  all  astringent  and  "repelling" 
medicines  in  favor  of  warm  sedative  applications,  such  as  decoction  of 
marshmallow  or  lily  roots,  henbane,  etc.  ;  when  the  pain  was  severe,  he 
prescribed  narcotics  internally,  such  as  laudanum,  "  Tinctura  Anodyna,"  or 
syrup  of  diacodium,  "in  a  convenient  dose."  He  recommends  that  an 
attempt  should  be  made  to  relieve  the  hardness  of  the  testicles  by  mer- 
curial inunction,  or  the  application  of  emplastrum  Vigo ;  the  testicle  was 
also  to  be  supported.  When  abscess  of  the  perineum  threatened,  he  or- 
dered cooling  ptisans,  cooling  and  anodyne  fomentations  of  bear's  breech 
(branca  ursida),  with  clysters  of  quassia  and  some  anodyne.  In  a  stillici- 
dium  it  was,  of  course,  necessary  "  to  correct  the  acrimony  of  the  semen," 

1  A  Treatise  on  the  Venereal  Disease,  vol.  i.    1737. 


64  ON    GONOKRHtEA. 

and  this  was  effected  by  means  of  softening  remedies,  such  as  "  cooling 
broths  and  apozems,"  after  which  the  relics  of  the  ulcer  were  to  be  deterged 
with  "  vulnerary  "  and  balsamic  remedies. 

Hunter's  Treatment. — Hunter  thought '  the  soothing  plan  the  best  at 
the  beginning.  When  the  violence  of  the  symptoms  had  abated,  astrin- 
gents might  be  employed.  He  considered  diuretics  had  their  advantages, 
and  that  injections  might  be  used.  He  employed  as  an  injection,  corrosive 
sublimate,  one  or  two  grains  to  an  ounce  of  rose-water,  also  opium  and 
lead  as  soothing  injections.  He  doubted  the  power  of  "the  vegetable 
mucilages  "  to  remove  scalding.  He  seems  to  have  made  little  use  of  in- 
ternal medicines,  and  not  to  have  had  much  faith  in  them.  Possibly  he 
was  too  much  occupied  in  his  vast  anatomical  and  physiological  researches 
to  have  had  time  to  establish  any  fixed  principles  of  treatment,  even  in  his 
own  mind. 

Howard's  Treatment. — Howard,  the  confidential  assistant,  as  he  puts  it, 
of  Percival  Pott  in  his  "  large  general  business,"  gives  2  a  very  careful  ac- 
count of  the  practice  of  his  day,  as  also  of  that  for  a  considerable  space  of 
time  previous.  He  draws  attention  to  the  great  discrepancy  of  views  as  to 
treatment,  and  remarks  that  gonorrhcea  "  has  not  only  been  frequently  but 
successfully  treated  in  many  different  ways." 

Howard  bled 3  in  almost  every  case,  leeched  when  there  was  much  in- 
flammation, kept  the  bowels  moderately  open,  recommended  warm  baths, 
opium,  and  a  cooling  and  well-regulated  diet.  He  considered  the  period 
following  the  decline  of  chordee  the  proper  one  for  administering  mercury. 
If  the  irritability  of  the  membrane  did  not  diminish  he  gave  bark  ;  he  also 
speaks  in  favor  of  blistering  the  perineum.  Cases  treated  in  this  way 
rarely  required  balsams,  such .  as  copaiba,  turpentine,  colophony  (pix 
grseca),  mastic,  and  so  on.  For  orchitis  the  horizontal  position,  and  sus- 
pension of  the  testis,  with  cooling  applications  of  lead.  Inflamed  prostate 
was  to  be  met  with  antiphlogistic  treatment.  Perineal  abscess  was  to  be 
freely  opened.  He  dreaded  injections  at  the  early  stage,  lest,  "  by  smoth- 
ering chancrous  infection  for  a  time,"  they  might  produce  "  future  symp- 
toms of  lues,"  or  stimulate  metastasis.  Perhaps  the  reader  has  heard  this 
kind  of  thing  about  injections  from  men  of  a  later  school  than  Howard. 
According  to  this  author  Pott  used  injections  freely. 

Foot's  Treatment. — Foot  injected4  with  a  preparation  of  blue  vitriol 
precipitated  by  means  of  lixivium  tartari,  the  precipitate  being  subse- 
quently dissolved  in  a  saturated  solution  of  volatile  sal  ammoniac.  This 
was  used  of  a  strength  of  five  grains  to  an  ounce  of  water.  With  it  he 
gave  daily  one  grain  of  calcined  mercury  and  half  a  grain  of  opium.  If 
the  inflammation  extended  along  the  urethra,  he  advised  soothing  applica- 

1  Op.  citat.  •  Op.  citat.  3  Ibid.,  vol.  iii.,  p.  51. 

4  Origin,  Theory,  and  Cure  of  the  Lues  Venerea.     1792. 


TREATMENT.  65 

tions,  such  as  constant  injections  of  warm  milk  and  water  with  the  appli- 
cation of  the  steam  of  hot  water.  He  thought  no  method  protracted  gon- 
orrhoea so  much  as  giving  purgatives.  For  gleet,  to  which  term  he  allows 
a  pretty  wide  latitude,  he  prescribed  bark,  steel,  the  cold  bath,  and  injec- 
tions ;  if  these  did  not  succeed,  copaiba  was  to  be  taken.  Chordee  he 
seems  to  have  left  pretty  much  to  time.  For  phimosis,  poppy  fomenta- 
tions and  poultices  containing  spirit ;  internally,  calcined  mercury.  If  in 
this  complication  the  fever  ran  high,  the  patient  was  to  be  bled  and  to 
take  antimony.  For  swelled  testicle  he  counselled  rest,  lotions  of  liquor 
ammonias  acetatis,  etc.  If  the  running  did  not  return,  and  the  testicle 
continued  to  swell,  he  resorted  to  bleeding,  leeches,  fomentations,  etc.  ; 
giving  at  the  same  tune  mercurius  calcinatus,  opium,  and  small  doses  of 
antimony. 

Sir  Astley  Cooper's  Treatment. — Sir  Astley  Cooper  purged  his  patients 
freely  with  salts  and  senna,  calomel  and  colocynth.  He  gave  carbonate  of 
potass  or  soda  as  a  drink,  or  liquor  calcis.  He  recommended  warm  bath- 
ing of  the  penis  ;  he  also  prescribed  liquor  potasses  with  conium  in  cam- 
phor mixture.  When  the  inflammation  had  subsided,  he  ordered  balsam 
of  copaiba  with  injections  of  sulphate  of  zinc  and  liquor  plumbi.  If  the 
disease  had  existed  some  little  time  when  he  first  saw  the  patient,  he  gave 
balsam  of  copaiba  at  once.  He  also  gave  cubebs  when  the  inflammation 
did  not  run  high  ;  and  it  appears  from  his  account  that  this  medicine  was 
so  little  known  at  that  time,  that  Cooper  had  never  heard  of  it  till  a  patient 
brought  him  some  to  try.  Yet  it  was  used  in  London  nearly  six  hundred 
years  ago,  a  toll  on  every  pound  of  it  carried  over  London  Bridge  having 
been  levied  as  far  back  as  1305. l  In  old-standing  cases  he  passed  bougies. 

Sir  Astley  had  the  courage  to  say  that  the  man  who  gave  mercury  in 
this  disorder  deserved  to  be  flogged  out  of  the  profession,  and  to  stigma- 
tize in  the  strongest  way  the  practice  which  then  prevailed  at  Guy's,  of 
sending  every  patient  affected  with  gonorrhoea  into  the  foul  ward,  where 
he  was  pretty  sure  to  be  drenched  with  mercury. 

Judd's  Treatment. — I  have  not  been  able  to  make  out  on  what  princi- 
ples Mr.  Judd  treated  his  cases,  or  what  he  considered  to  be  the  most  use- 
ful remedies.  He  sometimes  gave 2  calomel  and  colocynth,  with  fifteen- 
grain  doses  of  extract  of  cubebs,  sometimes  injections  of  nitrate  of  silver, 
3  j-  to  §  j. ;  in  other  cases  tincture  of  muriate  of  iron  as  an  injection,  with 
sulphate  of  magnesia  internally,  and  again  in  a  third  case  a  zinc  injection 
gr.  x.  to  §  j.  He  also  prescribed,  in  combination  with  purgatives,  essence 
and  balsam  of  copaiba  and  essence  and  spirit  of  cubebs,  without  assigning 
any  reason  for  the  variation,  except  such  as  his  readers  can  make  out  from 
the  history  of  the  case,  which,  so  far  as  I  can  see,  throws  no  light  on  the 
point. 

1  Pereira's  Elements  of  Materia  Medica,  p.  754.     1840.  *  Op.  citat. 

5 


66  ON    GONORRHOEA. 

From  this  time  forth  it  gradually  grows  more  impracticable  to  give  such 
an  analysis  as  shall  faithfully  reflect  the  views  of  those,  who  might  naturally 
be  supposed  to  represent  the  leading  opinions  in  matters  of  medicine. 
The  subject  has  become  too  bulky  to  allow  of  anything  like  a  full  account 
in  any  ordinary  work,  and  incomplete  reproductions  are  worse  than  use- 
less. What  I  have  to  say  of  their  views  may.  I  think,  be  more  fittingly 
appended  to  the  remarks  on  the  different  remedies  used  for  this  dis- 
order. At  one  time  I  purposed  examining  the  various  plans  of  treatment 
adopted  by  modern  authorities  in  gonorrhoea  ;  but  I  soon  found  it  was  im- 
possible to  carry  out  this  idea,  for  as  many  of  them  are  exactly  alike  in 
great  part  of  their  details,  the  same  arguments  would  require  to  be  urged 
each  time  the  separate  elements  of  treatment  came  to  be  discussed.  In 
the  interval  between  the  date  of  Judd's  work  and  the  present  time  thirty- 
five  methods  have  been  recommended  to  public  notice  ;  and  I  am  speaking 
here,  not  of  mere  suggestions  in  some  journal,  founded  perhaps  on  the 
evidence  of  two  or  three  cases,  or  of  some  novelty  in  the  shape  of  a  new 
injection,  but  of  more  or  less  complete  systems  of  both  internal  and  exter- 
nal therapeutics,  most  of  them  taught  by  men  of  great  experience  and 
ability,  attached  to  important,  often  special,  hospitals,  and  enjoying  large 
practices.  Many  of  these  methods,  it  is  true,  resemble  each  other  strongly, 
such  divergence  as  there  is  relates  chiefly  to  matters  of  detail,  but  others 
again  differ  so  widely  that  it  is  not  easy  to  understand  how  the  same  dis- 
ease can.  be  cured  by  means  so  opposite.  Let  any  one  contrast  the  plan 
pursued  by  Kuchenmeister '  with  that  laid  down  by  Fournier,  that  of 
Prettyman  or  Dupouy  with  that  of  Ricord,  the  method  of  Gamberini  with 
that  of  Bumstead,  and  say  if  such  diversity  as  the  subject  admits  of  can 
well  be  carried  farther. 

These  methods  embrace,  as  may  very  well  be  supposed,  most  of  the 
means  yet  recommended  against  this  disorder.  Treatment  on  general 
principles,  unbounded  reliance  on  specifics,  combinations  of  the  two,  local 
treatment  now  elevated  to  the  first  rank,  now  subordinated  to  medicines 
or  just  tolerated  under  protest.  Yet  from  all  this  collision  of  views,  from 
this  vast  aggregate  of  experience,  not  one  fixed  principle,  one  single  gen- 
eral rule  of  treatment  can  be  deduced,  not  one  unerring  clue  to  guide  the 
practitioner  an  inch  on  his  path ;  out  of  the  many  items  of  which  these 
various  systems  are  composed,  not  one  can  be  found  respecting  which  the 
observations  of  one  author  are  not  refuted  by  those  of  another.  If  amidst 
these  conflicting  views  we  could  find  some  secure  basis  for  drawing  conclu- 
sions, if  an  analysis  of  each  separate  system  would  place  us  in  a  position 
to  ascertain  how  many  cases  are  cured  by  it  out  of  every  ten  or  every  hun- 
dred subjected  to  it,  and  in  what  space  of  time,  we  might  arrive  at  some  defi- 
nite opinion  ;  as  it  is  we  are  left  to  infer  that  each  surgeon  is  equally  satis- 

1  Deutsche  medizinische  Wochenschrift,  S.  305.     1880. 


TREATMENT.  67 

fied  with  his  own  plan,  and  that  all  these  various  modes  of  treatment  are 
equally  successful.  Whether  the  surgeon  uses  injections  or  not,  whether 
he  give  specifics  or  treats  on  general  principles,  seems  a  matter  of  indiffer- 
ence ;  methods  diametrically  opposed  to  each  other  conduct  to  one  common 
goal.  The  proper  mode  of  giving  the  same  medicines,  and  the  account  of 
what  follows  from  employing  the  same  treatment  are  quite  as  conflicting. 
I  suppose  no  one  who  has  read  the  works  of  the  two  authors  can  doubt 
that  Mr.  Acton  borrowed  his  treatment  chiefly  from  M.  Bicord,  and  in- 
tended his  readers  to  understand  that  it  never  failed.  M.  Fournier's  view 
of  therapeutics  agrees  very  closely  with  that  of  his  illustrious  master  ;  but 
the  two  last  famous  men  tell  us  that  failure  is  but  too  frequently  the  result 
with  them ;  that  only  too  often  they  find  they  can  do  no  more,  and  then 
they  say  the  secret  is  to  try  to  do  nothing. 

Here,  then,  we  find  irreconcilable  difference  of  views  about  the  most 
simple  facts,  and  ever-recurring  conflict  of  opinion.  I  suppose  it  is  a  natu- 
ral and  therefore  inevitable  result  of  the  different  constitution  of  the  hu- 
man brain,  Nature  having  designed  that  men  should  no  more  exactly  think 
alike  than  that  they  should  exactly  resemble  each  other  in  features ;  and 
there  is  nothing  left  for  us  but  to  conclude,  that  were  a  perfect  system  of 
medicine  established  to-morrow,  it  would  at  once  be  assailed  more  or  less 
actively  on  all  sides  until  it  had  been  overthrown.  Nor  is  this  tendency  in 
any  way  peculiar  to  any  given  state  of  our  art — to  any  particular  era. 
Possibly  it  may  become  more  developed  with  greater  cultivation  of  medi- 
cine. Lord  Bacon  well  observes,  that  "  empirics  and  old  women  are  more 
happy  many  times  in  their  cures  than  learned  physicians,  because  they  are 
more  religious  in  holding  their  medicines,"  and  I  am  inclined  to  think 
that  multiplicity  here  proves  something  in  favor  of  his  assertion ;  or,  at 
any  rate,  that  if  physicians  nowadays  treat  gonorrhoea  better  than  empir- 
ics, the  system  is  still  subject  to  that  fatal  defect  which  in  Bacon's  day 
often  reduced  their  skill  to  the  level  of  that  of  old  women,  and  which  is 
still  such  a  source  of  weakness — a  constant  desire  to  try  new  remedies  and 
other  systems  without  sufficient  grounds. 

How  we  are  to  deal  with  those  authors  who  give  no  opinion  on  the  point 
I  am  at  a  loss  to  make  out ;  I  suppose  they  too  are  satisfied  with  their  own 
systems.  In  a  former  edition  I  gave  an  analysis  of  nine  different  methods 
then  quite  recently  recommended.  Of  these  eight  represented  the  prac- 
tice at  as  many  of  the  leading  hospitals  in  London. '  With  the  exception  of 
that  at  St.  Bartholomew's,  where  the  treatment  was  said  to  be  invariably 
successful,  no  opinion  was  offered  on  this  point,  and  the  only  conclusion  to 
arrive  at  was  that  seven  opposite  methods  must  be  equally  efficacious,  and 
that  had  ten  times  the  number  of  hospitals  been  reported  upon  the  result 
would  have  been  ten  times  as  much  conflict  of  testimony.  Under  these 

'Condensed  from  reports  in  the  Lancet,  vol.  i.,  pp.  331,  362,  458.     1867. 


68  ON    GONORRHCEA. 

circumstances,  it  appears  to  me,  that  to  extend  such  observations  can  only 
increase  the  bewilderment  which  the  reader  must  necessarily  feel  on  notic- 
ing such  a  uniformity  of  effect  from  such  a  diversity  of  causes.  We  may 
as  well  once  for  all  admit  that  the  question  of  treatment  is  gravitating  into 
a  state  of  hopeless  confusion  ;  and  that  the  surgeon  who  has  mastered  all 
the  literature  of  the  subject,  will,  so  far  as  reading  goes,  scarcely  be  better 
qualified  to  treat  his  patients  successfully  than  the  student  who  confines 
himself  to  the  first  book  which  his  teachers  recommend  to  him. 

I  have  now  endeavored  to  give  the  reader  chapter  and  verse  for  the 
three  postulates  I  ventured  to  bring  forward,  namely  :  1.  That  except 
with  respect  to  injections  treatment  has  not  changed  so  much  within  the 
last  century  or  two  as  might  have  been  expected.  2.  That  there  prevails 
an  irreconcilable  discrepancy  as  to  the  best  method  of  coping  with  this 
disorder.  3.  That  the  ordinary  method  of  stating  the  results  of  treat- 
ment does  not  enable  the  reader  to  form  a  positive  opinion  as  to  the  rela- 
tive value  of  the  remedies  actually  employed.  Consequently  I  see  no  way 
of  getting  at  the  truth  but  by  the  most  rigorous  search  into  the  qualities, 
real  or  supposed,  of  each  substance  experimented  upon,  and  this  I  have  at- 
tempted to  the  best  of  my  ability.  There  are,  however,  one  or  two  points 
in  connection  with  this  subject,  such  as  the  expectant  treatment,  which  had 
better  be  discussed  before  taking  up  the  subject  of  the  remedies  for  gon- 
orrhoea. 

Expectant  Treatment. — This  system  has  at  one  time  or  other  had  advo- 
cates of  such  capacity  that  it  cannot  be  passed  over.  Some  few  years  ago 
it  found  a  champion  in  Dr.  Chambers,  of  St.  Mary's  Hospital.  This  gen- 
tleman says  '  that  gonorrhoea  is  naturally  a  most  mild  disease  both  in  the 
male  and  female,  and  if  left  to  itself  will  get  well  in  a  short  time,  occa- 
sionally in  four  or  five  days,  while  the  simplest  treatment  will  remove  it  in 
a  fortnight  if  it  be  not  made  severe  by  the  folly  of  the  patient  or  his  medi- 
cal attendant.  "I  consider,"  he  says,  "all  primary  heroic  treatment  of 
urethral  discharges  a  most  unjustifiable  interference  with  nature." 

It  is  not  very  easy  to  imagine  how  any  one  could  argue  in  favor  of  a 
more  hopeless  cause.  There  is  no  evidence  brought  forward  in  support  of 
a  statement  which  runs  quite  counter  to  the  experience  of  the  greatest 
men  who  have  studied  the  disease.  What  they,  after  mature  deliberation, 
say,  utterly  negatives  the  idea  of  gonorrhoea  being  so  easily  managed  by 
the  simple  process  of  letting  it  alone. 

I  shall  state  further  on  my  reasons  for  thinking  that  this  kind  of  dis- 
belief in  the  powers  of  medicine  is  unfounded,  and  that  the  treatment  I 
have  ventured  to  recommend  will  on  an  average  always  cure  gonorrhoea  in 
less  time  than  it  requires  to  wear  itself  out.  I  regret  that  I  cannot  give  a 
fuU  account  of  what  Dr.  Chambers's  treatment  is,  but  the  fact  is  that  the 

1  Clinical  Lectures  on  Gonorrhoea.     Lancet,  vol.  i.,  p.  582.     1861. 


TREATMENT.  69 

part  of  liis  lecture  devoted  to  gonorrhoea  only  occupies  half  a  column  of 
the  Lancet. 

I  have  collected  a  good  many  cases  in  which  the  expectant  treatment 
had  been  pretty  fairly  tried,  by  the  patient,  however,  rather  than  the  sur- 
geon, and  where  the  gonorrhoea  disappeared  quickly  of  its  own  accord. 
But  in  all  these  I  had  to  depend  on  the  unsupported  evidence  of  the 
patients,  which  I  need  scarcely  say  is,  with  all  conceivable  good  faith  on 
their  part,  almost  useless  in  a  scientific  point  of  view.  When  a  man,  on 
whose  truthfulness  we  feel  able  to  rely,  tells  us  that  a  discharge  went  away 
in  a  few  days  without  his  doing  anything  for  it,  we  at  once  admit  the  fact ; 
but  it  would  be  a  step  of  a  totally  different  nature  to  accord  to  such  a  fact 
any  value  in  determining  the  average  duration  of  gonorrhoea  under  the 
influence  of  expectant  treatment.  Yet  this  is  the  only  evidence  I  have 
been  able  to  procure,  and  so  far  as  I  can  make  out  it  is  the  only  evidence 
employed  by  those  who  recommend  this  system.  Though  I  have  often 
heard  of  such  events,  I  have  never  yet  seen  a  gonorrhoea  run  its  course 
and  get  quite  well ;  indeed,  I  need  scarcely  say  that  the  vast  majority  of 
patients  would  not  give  a  surgeon  the  opportunity  of  trying  such  an 
experiment.  They  go  to  him  expecting  he  will  do  his  best  to  free  them 
from  a  disagreeable  complaint,  and  any  patient  who  found  his  surgeon 
doing  nothing  would  naturally  imagine  he  could  do  that  as  well  himself. 
Hospital  in-door  practice  would  alone  afford  a  proper  opportunity,  and  in 
that  department  I  believe  the  experiment  has  not  yet  been  tried. 

But  for  one  case  where,  according  to  the  patient's  version,  so  fortunate 
a  termination  as  spontaneous  extinction  of  a  gonorrhoea  thus  treated  took 
place,  there  were  at  least  ten  where  the  result  was  widely  different,  where 
the  patients  had,  according  to  their  own  statement,  taken  all  possible  care 
not  to  aggravate  the  disorder,  abstaining  carefully  from  stimulants,  etc., 
and  where  the  cases  had  lasted  months  and  even  years,  and  might  have  in  all 
probability  lasted  much  longer  were  it  not  that  even  the  most  indifferent 
persons  generally  get  wearied  in  the  long  run  of  seeing  the  hateful  dis- 
charge forever  hanging  about  them,  and  at  last  make  up  their  minds  to  do 
what  they  should  have  done  first,  go  to  some  surgeon  who  will  set  them 
right.  Indeed,  I  suppose  it  is  difficult  to  limit  the  length  of  time  gonor- 
rhoea might  sometimes  last  if  systematically  neglected,  and  even  where 
very  carefully  attended  to.  Kicords  relates '  a  case  where  the  patient  had 
suffered  from  gonorrhoea  for  more  than  forty  years,  and  I  have  seen  several 
where  the  patient  had  had  it  for  five,  six,  or  seven,  and  in  two  instances 
for  upward  of  twelve  years.  True,  in  all  these  cases  there  was  not  much 
running,  but  it  was  distinctly  purulent ;  the  severity  of  the  first  symptoms, 
too,  had  long  passed  off,  but  it  was  evident  that  a  slight  irritant  would 
speedily  rouse  them  to  very  unpleasant  activity,  a  fact  of  which  the  pa- 

'  Lettres  sur  la  Syphilis,  p.  120. 


70  ON    GONORRHOEA. 

tients  were  quite  aware.  Mr.  Johnson  very  justly  remarks,  that  "  the  sur- 
geon who  calculates  in  a  sanguine  manner  on  the  natural  cure  of  gonor- 
rhoea will  probably  be  more  remarkable  for  patience  than  success."  It  is, 
according  to  him,  repeating  the  old  story  of  the  rustic  by  the  bank  of  the 
river,  waiting  till  the  stream  ceases  to  flow  ! 

Gonorrhoea  as  a  Cause  of  Stricture. — Again,  it  is  to  be  borne  in  mind, 
that  should  the  experiment  of  leaving  gonorrhoea  to  itself  fail,  and  should 
the  disease  in  consequence  last  a  certain  time,  it  will,  in  a  given  percentage 
of  cases,  certainly  be  followed  by  swelled  testicle  and  stricture.  In  many 
old-standing  gonorrhoeas  the  surgeon,  on  passing  the  bougie,  finds  a  certain 
degree  of  contraction,  with  tenderness  of  the  urethra  at  different  spots,  and 
often,  even  when  there  is  no  discharge  from  the  urethra  at  the  moment  of 
examination,  small  clots  or  strips  of  pus  and  mucus  will  be  found  adhering 
to  the  bougie  when  it  is  withdrawn.  There  is  indeed  reason  to  believe  that 
in  some  persons  a  tendency  to  stricture  takes  place  almost  as  soon  as  the 
gonorrhoea  has  well  established  itself,  and  that  up  to  a  certain  degree,  at  any 
rate,  it  constantly  and  uniformly  tends  to  get  tvorse.  Hunter's  old  rival,  Jesse 
Foot,  pertinently  says,  "that  a  gonorrhoea  may  cease  to  be  a  gonorrhoea  if 
left  to  its  own  action  may  be  true,  but  it  may  also  be  as  true  that  it  might  not 
cease  to  be  a  gonorrhoea  till  it  had  reduced  the  organism  within  the  urethra 
to  a  condition  which  could  not  afterward  be  restored  to  a  sound  state." 

Hunter  and  many  other  surgeons  have,  it  is  true,  considered  the  theory 
of  stricture  arising  from  gonorrhoea  as  a  mere  prejudice,  and  as  I  was  anx- 
ious to  investigate  this  subject  carefully,  and  had  no  theory  to  serve,  I  made 
for  a  long  time  a  careful  collection  of  cases,  going  into  the  most  minute 
details..  I  was  at  last  obliged  to  confess  that  the  mere  history  of  the  case, 
as  given  by  the  patient,  always  offers  insufficient  and  doubtful  data.  How- 
ever, after  carefully  weighing  what  facts  I  could  collect,  I  think  myself 
fairly  warranted  in  drawing  the  following  conclusions,  which,  after  all,  con- 
tain nothing  new : 

1.  That  strictures  arise  in  persons  who  have  never  had  a  gonorrhoea,  and 
in  some  at  such  an  early  age  as  to  preclude  all  probability  of  gonorrhceal 
infection. 

2.  That  occlusions  of  a  similar  character  occur  in  mucous  canals,  with- 
out being  preceded  by  any  inflammatory  and  purulent  discharge. 

3.  That  the  progress  of  the  stricture  seems  to  bear  no  sort  of  proportion 
to  the  duration  or  severity  of  the  gonorrhoea. 

4.  That  the  proportion  of  patients  attacked  by  stricture  to  those  who 
suffer  from  gonorrhoea  is  extremely  small. 

5.  That  gonorrhoea  appears  to  develop  the  tendency  to  stricture  in  per- 
sons who  would  otherwise  never  have  been  assailed  by  it. 

But  I  need  scarcely  point  out  to  the  reader  how  untrustworthy  such 
conclusions  are.  To  get  at  the  truth  we  require  information  which  we  are 
never  likely  to  procure  ;  for,  first  of  all,  it  would  be  necessary,  before  at- 


TREATMENT. 


71 


tempting  any  deduction,  to  divide  the  whole  male  population  of  a  given  dis- 
trict into — a,  those  who  had  had  gonorrhoea,  and  b,  those  who  had  not ;  sec- 
ondly, the  males  must  be  again  separated  into  c,  those  suffering  from,  and 
d,  those  free  from  stricture.  The  proportion  of  c  to  a  and  6  would  give  us 
something  like  data. 

The  following  table  is  taken  from  the  Edinburgh  Medical  and  Surgical 
Journal. '  It  contains,  as  the  reader  will  observe,  cases  of  gonorrhoea  treated 
in  different  ways  in  the  hospital  of  the  Castle  of  Edinburgh  by  Messrs. 
Johnston  and  Bartlett : 

TABLE  L 

Cases  of  Gonorrhoea  treated  in  different  ways. 

CASES  TREATED  WITH    REST  AND  ABSTINENCE. 

No.  of  Cases.  Result  of  Treatment. 

3 Discharged  cured  in    3  days. 

2 "                     5  " 

4 "                      7  " 

4 "                    10  " 

1 "                    18  " 

1 «                    23  " 

Or  an  average  of  8£  days. 


Cases  treated  with 
Cubebs. 

2  were  cured  in  4  days. 
2  "         in  5     " 

4          "         in  6     " 
Average  5£  days. 


Cases  treated  with. 
Capsicum. 

4  were  cured  in    8  daya 
4          "          in  12    " 
2          "          in  24    " 

Average  13  k  days. 


Cases  treated  with 
Camphor. 

1  was  cured  in  5  days. 
1         «          in  8    " 
1         «          in  14   " 

Average  9  days. 


To  these  may  be  added  the  cases  tabulated  by  Mr.  Macfie  Campbell, 
of  the  Dreadnought  Hospital,4  who  found  that  the  average  duration  of 
gonorrhoea,  treated  with  copaiba  or  cubebs,  was  thirteen  days. 

It  will  be  observed  that  of  these  cases  fifteen  treated  with  fasting  and 
quiet  were  cured  in  three  to  twenty-three  days  ;  eight  by  cubebs,  in  four 
to  six  days ;  three  by  camphor,  in  five  to  fourteen  days  ;  ten  by  capsicum, 
in  eight  to  twenty-four  days  ;  whereas  twenty  treated  with  injections  of  lapis 
infern.  3  j.  to  |  j.  were  cured  in  three  to  forty-two  days.3  With  the  excep- 
tion of  the  cases  in  which  cubebs  and  injections  were  given,  these  figures 
may  be  held  to  represent  pretty  well  the  effects  of  expectant  treatment,  as 
it  is  difficult  to  believe  that  either  capsicum  or  camphor  would  materially 
shorten  the  course  of  gonorrhsea  ;  any  rate,  we  do  not  as  yet  know  that 


1 1818,  p.  264. 


5  Lancet,  vol.  i.,  p.  73.    1871. 


3  Op.  citat.,  p.    263. 


72  ON    GONORRHOEA. 

they  do.  I  have  cited  this  list,  as  it  is  the  only  thing  in  the  shape  of  statis- 
tics bearing  on  this  point  that  I  have  met  with.  The  results  of  treatment,  as 
given  in  it,  by  no  means  harmonize  with  my  experience,  the  time  for  cure 
appearing  to  me  much  too  short. 

Homoeopathy. — Of  that  singular  compromise  with  expectant  treatment 
called  homoeopathy  I  have  no  personal  experience  to  record  beyond  what 
I  have  learned  from  patients,  and  their  report  is  to  the  effect  that  the  ac- 
tion of  the  remedies  is  so  slight  as  to  elude  the  closest  observation.  I 
fancy,  too,  that  even  the  supporters  of  homoeopathy  would  be  puzzled  to 
bring  forward  a  series  of  cases  showing  that  gonorrhoea  was  cured  more 
quickly  by  infinitesimal  doses  than  by  active  allopathic  treatment.  Till 
that  is  done,  or  at  any  rate  attempted,  it  will  be  unnecessary  to  pursue  the 
subject  farther. 


CHAPTER  IV. 

TREATMENT  (CONTINUED). 

X 

Classification  of  Remedies. — The  most  practical  arrangement  of  the 
various  means  of  treatment  for  gonorrhoea  appears  to  me  a  division  into  A, 
internal  remedies ;  B,  external  applications,  such  as  lotions  and  fomenta- 
tions ;  and  0,  direct  applications,  comprising  injections,  caustic,  bougies, 
and  so  on. 

A.  INTERNAL  REMEDIES.  L  Copaiba. — Perhaps  without  exception  the 
most  potent  and  generally  used  of  all  the  internal  remedies  for  gonorrhoea 
is  copaiba,  one  of  the  most  nauseous  drugs  ever  found  out.  Excepting, 
perhaps,  the  plan  devised  by  Mr.  Thorn,  no  method  of  really  disguising  its 
taste  without  impairing  its  efficacy  has  been  discovered,  and  other  objec- 
tions apart,  this  alone  is  an  insuperable  drawback.  I  have  heard  scores  of 
persons  say  that  they  would  rather  leave  a  gonorrhoea  to  itself  than  again 
take  copaiba.  Besides,  in  a  certain  percentage  of  cases,  copaiba,  if  given 
in  sufficiently  large  doses  to  influence  the  discharge,  brings  on  nausea, 
retching,  and  vomiting,  griping  and  purging,  great  irritability  of  the 
stomach  and  often  of  the  temper  too.  Symptoms  of  strangury  not  unfre- 
quently  follow  its  exhibition.  Mr.  Johnson  has  seen  '  acute  inflammation 
of  the  bladder,  extensive  suppuration  in  the  thigh,  severe  gastro-enteritis, 
and  even  death  follow  the  use  of  it.  M.  Ricord  has  seen2  serious  effects 
on  the  nervous  system,  such  as  partial  paraplegia  and  temporary  hemiple- 
gia,  follow  from  the  same  cause,  and  Mr.  Lee  suggests  3  that  organic  dis- 
ease of  the  kidneys,  thickening  of  the  coats  of  the  capillary  tubes,  etc., 
may  be  caused  by  giving  it  for  a  lengthened  period.  In  several  instances, 
when  taken  during  an  epidemic  of  cholera,  it  appears  to  have  determined 
an  access  of  this  complaint.  Dr.  Durkee  mentions  4  an  instance  where  a 
patient  was  attacked  with  a  species  of  cholera,  the  symptoms  being  grip- 
ing, vomiting,  and  purging,  from  taking  merely  half  an  ounce.  Again,  in 
certain  constitutions  it  brings  on  pain  in  the  region  of  the  kidneys,  hsema- 
turia,  severe  headache,  giddiness.  The  vomiting,  too,  it  must  be  remem- 
bered, which  copaiba  brings  on  is  horrible,  and  few  but  the  most  resolute, 
who  have  once  suffered  in  this  way,  can  be  induced  to  make  a  second  trial. 


1  Op.  citat.,  p.  52,  etc.  *  Traiti  Pratique,  p.  732. 

3  St.  George's  Hospital  Reports,  vol.  vi.,  p.  52.  4  Op.  citat.,  p.  39. 


74  ON   GONORRHCEA. 

One  pretty  certain  result  of  all  this  kind  of  thing  is,  that  some  patients 
give  up  treatment  in  despair,  others  are  driven  to  try  some  dangerous 
remedy,  such  as  a  very  strong  or  irritating  injection,  e.g.,  one  of  bichloride 
of  mercury,  a  mistake  I  have  known  several  times  committed  ;  while  a  few 
try  to  overwhelm  the  disease  by  swallowing  an  inordinate  quantity  of  wine 
or  spirit,  a  freak  of  very  probable  occurrence,  inasmuch  as  probably  every 
patient  has  in  his  turn  heard  some  wonderful  story  of  gonorrhoea  being 
cured  in  this  way.  When  to  all  this  is  added  the  fact  that  copaiba  is  never 
really  indispensable,  inasmuch  as  every  case  that  can  be  cured  may  be  got 
rid  of  without  resorting  to  it,  I  think  there  are  very  strong  grounds  for 
the  views  just  laid  down. 

It  will  perhaps  be  said  in  reply,  that  such  objections  apply  to  all  reme- 
dies ;  that  any  potent  drug  taken  in  excess  will  produce  serious  symptoms  ; 
that  to  discard  all  remedies  for  such  reasons  would  be  to  reduce  medicine 
to  a  nullity.  I  have  heard  such  a  method  of  getting  over  these  objections 
repeatedly  put  forward,  but  it  does  not  meet  the  case.  These  disagreeable 
results  occur  when  copaiba  is  given  in  doses  which  very  good  surgeons  have 
not  hesitated  to  recommend. 

Even  were  it  an  infallible  remedy  for  the  discharge,  its  disagreeable 
action  in  so  many  cases,  and  the  smell  it  communicates  to  the  breath  and 
urine,  would  always  be  obstacles  to  its  use.  It  is,  however,  anything  but 
infallible.1  It  fails  in  a  large  proportion  of  cases  it  is  given  for  ;  it  fails  in 
every  dose  and  in  every  form.  Half-ounce  doses  are  no  more  to  be  relied 
on  than  those  of  half  a  drachm  ;  it  is  often  no  more  to  be  trusted  to  in  the 
form  of  capsules  than  in  that  of  injections,*  enemata,3  or  suppositories. 
Now,  as  no  amount  of  experience  will  enable  the  surgeon  to  diagnose  at  the 
outset  those  cases  in  which  copaiba  will  be  useful  from  those  in  which 
it  will  almost  certainly  fail,  it  necessarily  follows  that  every  surgeon  who 
treats  all  cases  with  copaiba,  and  there  are  plenty  who  do  so,  must  give  it 
in  many  instances  where  it  is  sure  to  be  of  no  service.  It  seems  to  me  that 
there  is  no  getting  over  this  fact. 

It  appears  that  whatever  disadvantages  the  use  of  copaiba  may  entail  it 
still  has  numerous  advocates.  My  own  experience  has  satisfied  me  that 
the  practice  of  giving  it  is  very  extensively  diffused,  and  Mr.  Wheeden 
Cooke  confirms  this.  On  inquiry  at  the  London  Custom  House,  he  found 
that  during  the  first  ten  months  of  the  year  1859,  no  less  than  118,396 
pounds  of  copaiba  were  admitted,  or  at  the  rate  of  151,075  pounds  annu- 
ally— a  quantity  sufficient  to  supply  five  hundred  thousand  people  every 
year  with  a  strong  dose  three  times  a  day  for  nearly  four  weeks  ! 4 


1  Johnson  :  Op.  citat  ,  p.  88.     Ricord,  Traite  Pratique,  p.  726. 
1  Sigmund  has  found  that  injections  of  the  urine  of  persons  taking  copaiba  are 
inert.     Schmitt's  Jahrbuch;  also  Braithwaite's  Retrospect,  vol.  xxxviii.,  p.  451. 
3  British  and  Foreign  Medical  Review,  July,  1856. 
4 Lancet,  vol.  i.,  p.  93.     1860. 


TREATMENT. 


75 


The  following  cable,  drawn  up  from  cases  in  my  own  practice,  contains 
some  statistics  which  may  be  of  value  to  those  really  desirous  of  investigat- 
ing the  subject : 

TABLE  H. 

Cases  treated  urith  Copaiba. 


Initials. 

Nature  of  Case. 

Treatment. 

Result. 

1 

J.  D. 

Mild    gonorrhoea   of    Copaiba.     Injections  of 

Not  quite  cured  at  end 

three    months'        sulphate  of  zinc  and 

of  27  days. 

duration.                        nitrate  of  silver. 

2 

W.  J. 

Gonorrhoea  of  three    Potassio-tartrate  of  anti- 

At  the  end  of  86  days 

or  four  days'  stand- 

mony,  copaiba,   tur- 

left     off    attending. 

ing. 

pentine,  and  steel. 

Not  quite  cured. 

3 

— 

Gonorrhoea  of  three 

Pulv.  salin.   At  the  end 

Cured  in  65  days. 

days'  standing. 

of  fourteen  days  co- 

paiba, and  then  tur- 

pentine.     Afterward 

colchicum. 

4 

J.  S. 

Ordinary  gonorrhoea. 

Had   been   treated  for 

At  the  end  of  this  time 

seven    months   with 

he  was  still  suffering 

sulphate  of  magnesia, 

from    gleet,     cloudy 

. 

copaiba,  etc. 

urine,  and  pain  over 

the  bladder. 

5 

L.  H. 

Gonorrhoea   of   a 

Injections   and   purga- 

Cured in  52  days. 

month's  standing. 

tives    for     fourteen 

days.      Pulv.    salin. 

and  inject,  of  sulph. 

of    zinc.       Copaiba, 

turpentine,  and  pulv. 

salin.     Injections. 

6 

W. 

Gonorrhoea  of  a 

Magnes.     sulph.,    fol- 

Not quite  cured  at  the- 

week's  duration. 

lowed  by  copaiba  and 

end  of  3  months.  Sub- 

nitrate of  potass.   In- 

sequently  he  reports- 

jections  of  sulph.  of 

that  the  disease  died 

zinc. 

out  without  anything 

further    being    done 

for  it. 

7 

J.  W. 

Gonorrhoea  of  some 

Aperients  and  copaiba 

Rapid       improvement. 

days'  standing. 

perseveringly     used 

Severe    relapse,    ap- 

for seven  months. 

parently   from   bath- 

ing.    At  the  end  of  7 

months  scarcely  well. 

8 

Mr.  N. 

Gonorrhoea,     second 

Copaiba,   liquor  potas- 

Cure  twice  deferred  by 

attack,  very  severe. 

saj,   compound   calo- 

his giving   up  treat- 

mel pill  at  night. 

ment  just   as  he  ap- 

peared to  be  getting 

quite  well. 

9 

Mr.  R. 

Gonorrhoea   of    four 

Copaiba  and  liquor  po- 

Discharge    removed   in. 

days'    stand  ing, 

tassae  with  five  grains 

3  months. 

complicated  with  a 

of    blue   pill    every 

sore  on  the  penis. 

night    for     a     short 

time.     Injections   of 

nitrate  of  silver  and 

sulph.  of  zinc. 

10 

Mr.  W. 

Gonorrhoea  of  a  fort- 

Copaiba,   cubebs,    zinc 

Little   improvement    at 

night's    standing  ; 

injections.       Almost 

the  end  of  12  weeks. 

first  case. 

constant  rest. 

76 


ON    GONORRH(EA. 


Initials. 

Nature  of  Case. 

Treatment. 

Result. 

11 

Mr.  E. 

Gonorrhoea  of    four 

Brisk    purgatives,    co- 

Cured in  about  7  weeks. 

days'       standing  ; 

paiba,  liquor  potassse, 

second  attack.                pil.    hydrarg.    chlor. 

comp.     Injections  of 

arg.    nit.    and    zinc.  ' 

sulph. 

12 

Mr.  B. 

Gonorrhoea  of  some 

Copaiba,   liquor  potas- 

At  the  end  of  2  months 

weeks'  standing. 

sae,   compound  calo- 

still  some    gleet    re- 

mel pill. 

maining. 

13 

A.  T. 

Ordinary  gonorrhoea. 

Took   six   drachms   of 

Still  some  purulent  dis- 

copaiba,     and      the 

charge    remaining    at 

same  amount  of  spirit 

the  end  of  that  time. 

of  nitric  ether,  every 

week  for  one  year. 

14 

Mr.  H. 

Ordinary  gonorrhoea. 

Took  two  pints  of  co- 

No better  at  the  end  of 

Patient  very  deli- 

paiba in  two  months, 

the  time. 

cate. 

under  the  care  of  an 

experienced  surgeon. 

15 

C.S. 

Simple  gonorrhoea. 

Took   half   a    pint    of  j  Discharge  diminished  to 

copaiba  a  month  for 

a  very  small  amount  ; 

four  months. 

returned   directly  on 

the  copaiba  being  left 

off. 

16 

Mr.  P. 

Rather  severe.     Pa- 

Copaiba in  small  doses, 

Little   if   any  improve- 

tient     himself      a 

and   then   an  ounce        ment  at  the  end   of 

surgeon. 

daily  for  above   two 

this  time. 

months.    • 

I  could  easily  lengthen  this  list,  but  I  cannot  see  that  doing  so  would 
serve  any  useful  purpose.  If  what  has  been  said  will  not  work  conviction, 
I  am  afraid  but  a  small  amount  of  faith  would  be  gained  by  constructing 
a  more  elaborate  table.  It  is  of  little  use  to  accumulate  evidence  when 
the  reader  is  indifferent  or  has  resolved  beforehand  that  he  will  not  be 
convinced.  I  heard  a  surgeon  say  before  the  Medical  Society  of  London, 
that  he  did  not  believe  gonorrhea  could  be  cured  without  copaiba.  The 
reader's  experience  will  possibly  supply  him  with  equally  striking  instances. 
Of  what  use  then  can  be  the  most  positive  proof  in  such  cases  ? 

It  may  be  supposed  that  the  copaiba  here  was  given  injudiciously,  and 
that  the  surgeon  had  not  waited  till  the  inflammation  was  subdued,  or 
that  the  patient  was  refractory  or  intemperate.  Nothing,  however,  could 
be  more  incorrect ;  case  eighth  excepted,  most  of  them  were  model  pa- 
tients— men  really  anxious  to  get  well.  In  the  cases  treated  by  myself, 
every  precaution  I  had  ever  found  of  service  was  used,  for  at  that  time  I 
believed  in  copaiba. 

Here  the  reader  may  object  that  I  am  making  out  a  case  against  co- 
paiba ;  so  far  from  this,  however,  I  am  quite  ready  to  admit  that  it  is  of  ser- 
vice in  a  great  number  of  cases,  though  I  myself  never  had  such  success 
with  it  as  some  writers  have  recorded.  Graves,  for  instance,  tells  us  that 
Dr.  Eoe  cured  his  patients  in  a  fraction  less  than  twelve  days.  I  never  could 
do  so  ;  and  besides,  I  think,  no  one  will  deny  that  it  does  not  cure  a  great 


TREATMENT.  77 

number  of  cases,  which  is  of  far  more  importance,  and  any  person  who, 
after  a  long  and  fair  trial,  finds  such  results,  is  plainly  justified  in  seeking 
for  a  more  generally  useful  remedy. 

Dose  and  Mode  of  giving  Copaiba. — It  would  be  satisfactory  if  those  who 
recommend  copaiba  would  really  come  to  an  agreement  as  to  the  most 
suitable  dose,  the  best  mode  of  giving  it,  and  the  period  at  which  it  should 
be  used.  At  present  any  person  seeking  for  reliable  information  on  these 
points  must  be  rather  apt  to  get  bewildered.  Some  surgeons  give  four- 
and-twenty  times  as  strong  a  dose  as  others.  Again,  it  was  stated  by  a 
reviewer  in  one  of  our  leading  medical  journals,  that  no  sensible  or  experi- 
enced surgeon  would  think  of  giving  copaiba  in  the  acute  stage  of  gonor- 
rhoea ;  and  many  authors,  M.  Bicord  for  instance,  strongly  advocate  the 
necessity  for  preliminary  steps  in  the  shape  of  antiphlogistics,  etc.  But  it 
is  quite  certain  that  numbers  of  patients  take  copaiba"  at  this  stage,  not 
only  with  impunity  but  with  benefit.  Irrespective  of  the  evidence  on  this 
head  met  with  daily  in  practice,  some  surgeons  distinctly  recommend  it  at 
this  period.  "It  would  appear,"  says  Dr.  Bumstead,1  "that  copaiba  can 
be  administered  with  safety  and  to  much  greater  advantage  in  the  acute 
stage  of  gonorrhoea,  or  at  an  early  period  of  the  stage  of  decline,  than  af- 
terward ;  and  the  same  is  true  of  cubebs."  My  own  experience  quite  con- 
firms this.  Dr.  Durkee  says  2  that  patients  have  taken  eight  drachms  at  a 
dose,  morning  and  evening,  in  the  most  acute  stage,  with  entire  success 
and  without  any  preparatory  treatment,  and  Dr.  Veale  goes  so  far  as  to 
maintain,3  that  the  great  error  in  giving  copaiba  is  allowing  the  acute  stage 
to  pass  before  administering  it,  and  ordering  too  small  doses.  As  to 
waiting  till  the  inflammation  is  subdued  before  administering  it,  it  is  to 
the  best  of  my  judgment  simply  useless.  Moreover,  copaiba,  when  it  does 
cure  the  disease,  cures  it  more  quickly  and  certainly  when  given  at  once 
than  after  antiphlogistics.  As  to  any  danger  from  using  it  in  this  way,  it 
is  imaginary.  The  few  recorded  instances  of  serious  or  fatal  results  from 
prescribing  it  in  the  acute  stage,  when  analyzed,  seem  to  have  been  due  to 
the  irritable  constitution  of  the  patient,  imprudence  and  intemperance  on 
his  part,  or  to  the  medicine  being  continued  when  it  was  manifestly  acting 
as  a  poison,  and  would  probably  have  occurred,  to  a  considerable  extent  at 
any  rate,  had  copaiba  been  administered  under  similarly  unfavorable 
auspices  at  another  stage.  I  have  repeatedly  known  it  make  strong  and 
temperate  patients  very  ill,  when  taken  for  a  mere  gleet. 

The  most  efficacious  way  of  giving  copaiba  is,  to  my  thinking,  in  com- 
bination with  liquor  potassse.  Spirit  of  nitric  ether  or  nitrate  of  potass 
may  be  advantageously  added,  as  may  the  compound  spirit  of  lavender, 
which,  mawkish  as  the  last  is  to  some  persons,  still  serves  to  disguise  the 
more  disagreeable  flavor  of  copaiba.  Mucilage  is  useful  for  the  same 

1  Op.  citat.,  p.  91.  •  Op.  citat.,  p.  38. 

3  Lancet,  vol.  ii.,  p.  2.    1855. 


78  ON    GONORRHOEA. 

purpose,  as  well  as  for  suspending  the  balsam.  Mint-water  is  the  best 
vehicle  that  I  know  ;  some  persons,  however,  strongly  object  to  the  taste 
of  it,  in  which  case  cinnamon-water  or  camphor  mixture  may  be  substi- 
tuted.1 With  regard  to  the  addition  of  such  substances  as  cubebs,  alum, 
tincture  of  cantharides,  of  sesquichloride  of  iron,  and  so  on,  I  have  had 
little  experience,  but  that  little  is  decidedly  unfavorable.  However  I 
give 2  two  or  three  formulae  taken  from  Dr.  Bumstead's  work. 

Dr.  Durkee  recommends  that  copaiba  should  be  taken  in  coffee,  wine, 
or  compound  tincture  of  cinchona.  Other  authors  have  suggested  sucking 
a  slice  of  lemon  immediately  afterward. 

It  seems  to  me  a  great  pity,  if  surgeons  will  continue  to  prescribe  and 
patients  to  take  copaiba,  that  Mr.  Thorn's  plan  is  not  tried.  This  gentle- 
man found  that  in  two  ounces  of  copaiba  there  are  five  parts  in  which  all 
the  virtues  of  the  balsam  reside,  and  eleven  parts  containing  only  useless 
and  nauseous  residue,  so  that  tons  of  dirt  are  annually  swallowed  by 
patients  to  no  purpose.  As  I  have  already  said,  Mr.  Tyrrell  obtained  the 
most  extraordinary  success  with  Mr.  Thorn's  extract,  and  certainly  the  trial 
could  not  have  been  made  by  better  hands ;  but  I  imagine  the  subject  has 
now  lapsed  into  oblivion,  although,  supposing  his  statements  and  those  of 
Mr.  Thorn  are  well  founded,  no  subsequent  method  of  prescribing  the 
drug  can  be  said  to  possess  so  fair  a  claim  to  public  notice. 

But  sometimes  the  question  is  not  what  is  the  most  efficacious  formula, 
but  what  preparation  the  patient's  stomach  can  bear  best.  Many  persons 
cannot  support  copaiba  in  a  liquid  form,  and  the  surgeon  looks  round  to 
see  in  what  solid  vehicle  it  can  be  got  to  stay  on  the  stomach.  There  is 
no  want  of  variety  here  ;  invention  has  been  racked  to  produce  something 
which  will  be  pleasant  or,  at  any  rate,  tolerable.  Capsules  of  all  kinds, 
sizes,  and  degrees  of  solubility  ;  pills,  lozenges,  dragees,  perles,  pastes, 
etc.,  have  been  brought  forward  in  plenty — some  of  them  ingenious 
enough.  I  believe  common  experience  has  united  to  condemn  them  one 
and  all  as  more  or  less  unreliable.  Perhaps  one  of  the  best  substitutes  for 
copaiba  in  the  form  of  mixture  is  that  of  the  balsam  solidified  by  mag- 
nesia ;  while  I  think  one  of  the  least  unpleasant  forms  is  that  adopted  by 
the  dispenser  at  University  College  Hospital,  who  prepares  the  copaiba 
with  honey,  sugar,  etc.,  so  that  it  resembles  "raspberry  jelly,"  though  one 
gentleman  who  had  tasted  it  spoke  of  it  with  horror.  The  formula  is 
given  at  full  length  in  the  number  of  the  Lancet  from  which  this  notice 

1  9 .  Copaibse  3  ij  (ad  3  iij),  Mucilaginis  acaciae  3  iv,  Liquoris  potasse  3  iss,  Potassae 
nitratis  3  iss,  Aq.  menth.  pip.  ad  §  vj.  TTl_.  Capiat  |  j.  bis  die. 

3  §.  Olei  Copaibas,  Olei  cubebae,  aa»  3  j,  Aluminis  3  ij,  Sacchari  albi  3  iv,  Mucila- 
ginis 3  iv,  Aquae]  r  ij.  TTj_.  A  teaspoonful  to  be  taken  three  times  a  day.  IJ.  Copaibae 
3  x.  Tinct.  cantharidis,  Tinct.  ferri  chloridi,  aa.  3  ij.  TT1_.  Dose  from  half  a  tea- 
spoonful  to  a  teaspoonful.  The  following  formula  is  copied  from  Dr.  Druitt's  Vade- 
Mecum,  1870,  p.  808: — R.  Copaibae  3  iij,  Olei  cubebae  m.  xx,  Spir.  aetheris  nit.,  Spir. 
lavandulae,  aa.  3  ij,  Olei  cinnam.  gutt.  ij,  Aquae  fl.  5  v.  Dosis  3  j.  ter  die. 


TREATMENT.  79 

is  taken.1  It  is  to  be  remembered,  however,  that  in  all  these  preparations 
one  very  important  ingredient,  which  figures  in  the  prescription  I  have  rec- 
ommended, the  liquor  potassae,  is  omitted.  It  is  said  that  the  alkali  turns 
the  copaiba  into  a  kind  of  soap,  insoluble  in  water,  but  in  my  experiments 
this  has  not  appeared  to  impair  the  efficacy  of  the  drug. 

One  thing  is  absolutely  necessary,  and  that  is  to  secure  pure  copaiba. 
Most  medical  men  have,  I  presume,  noticed  a  very  great  difference  in  dif- 
ferent samples  of  this  drug,  but  generally  speaking  they  have  little  idea  of 
the  extent  to  which  it  is  adulterated,  and  possibly  some  part  of  the  dis- 
crepancy in  the  results  from  using  copaiba  might  be  explained  by  the 
varying  degree  of  purity  in  which  it  is  met  with.  Rape-oil  seems  to  be  a 
favorite  ingredient  for  adulteration  ;  some  specimens  contain  a  large 
amount  of  this  useless  substitute.  Dr.  Durkee  says  that  this  adulteration 
is  easily  detected  by  dropping  a  little  of  the  fluid  into  water.  The  pure 
copaiba  assumes  a  spherical  form,  while  the  other  does  not.  Irrespective 
of  this,  two  kinds  of  copaiba  are  met  with  in  commerce.  Although  neither 
of  these  is  known  to  be  adulterated,  yet  one  is  naturally  much  weaker 
than  the  other  ;  the  stronger  one  solidifies  with  magnesia,  but  this  is  not 
the  case  with  the  other.  Again,  it  seems  that  unobjectionable  specimens 
differ  materially  as  to  the  amount  of  volatile  oil  they  contain,  the  percen- 
tage being  only  thirty  in  some,  and  as  high  as  eighty  in  others,2  and  as 
about  forty  per  cent,  seems  to  be  the  most  useful  standard,  it  has  been  rec- 
ommended that  only  tested  balsam  should  be  used.  Of  the  value  of  this 
oil,  when  given  separately,  I  have  had  no  practical  experience.  It  seems 
generally  agreed  that  we  can  depend  less  upon  it  than  upon  the  balsam, 
and  the  resin  only  of  copaiba  has  been  given,  it  is  said,  with  great  suc- 
cess. 

The  cutaneous  eruption  which  sometimes  follows  the  use  of  copaiba, 
"would  not,  in  my  opinion,  be  a  sufficient  ground  for  withholding  it.  For 
the  most  part  it  is  a  mild  form  of  urticaria,  distinguished  by  diffused  red- 
ness of  the  neck,  shoulders,  face,  and  upper  part  of  the  body,  accompanied 
generally  by  itching,  tingling,  a  feeling  of  not  being  well,  and  disorder  of 
the  stomach.  It  usually  passes  off  under  the  influence  of  a  saline  or  feb- 
rifuge, aided  by  rest  and  light  diet.  Some  serious  cases  have  happened. 
Occasionally  this  affection  has  given  rise  to  troublesome  mistakes.  Simon 
speaks3  of  a  case  where  the  house  surgeon  pronounced  a  patient  with  bal- 
sam rash  to  be  ill  of  scarlet  fever,  and  kept  him  six  weeks  in  doors  ;  and 
some  years  ago  a  gentleman  gave,  at  a  meeting  of  the  Medical  Society  of 
London,  the  particulars  of  a  case  where  the  same  error  seemed  to  have 
occurred,  the  speaker  himself  having  believed  the  eruption  to  be  that  of 
scarlatina. 

'Vol.  i.,  p.  570.    1871. 

2  American  Journal  of  Syphilography,  vol.  iii.,  p.  293. 

3Bicord's  Lehre  von  der  Syphilis. 


80  OK    GONORRHOEA. 

2.  Cubebs. — What  I  have  been  able  to  learn  respecting  the  action  of 
this  remedy  would  lead  me  to  place  it  pretty  much  on  a  level  with  copaiba, 
but  the  statements  about  it  are  so  vague  and  conflicting,  that  it  is  impossi- 
ble to  form  any  certain  conclusions.  One  observer,  Mr.  Broughton,  re- 
ports '  that  he  cured  nine  cases  out  of  ten  with  it.  Another,  Mr.  Crauf  ord, 
asserts a  that  it  fails  in  many  cases.  A  third,  Dr.  Pereira,  found  it  exert 3 
no  influence  over  the  disease  in  the  majority  of  instances,  a  statement 
which  is  much  more  in  unison  with  my  experience  than  that  of  Mr.  Brough- 
ton. Again,  it  is  pretty  widely  known  that  the  use  of  cubebs  in  this  com- 
plaint owes  its  origin  in  part  to  the  story  related  by  Sir  Astley  Cooper,  of 
one  of  his  patients  having  cured  himself  of  a  gonorrhea  with  this  drug  hi 
four  days,  or  more  strictly  speaking,  in  some  space  of  time  between  a 
Thursday  and  the  Monday  following ;  now  I  believe  this  experience  has 
been  so  rarely  verified  that  it  must  be  looked  upon  as  most  unusual.  Pos- 
sibly some  part  of  all  this  discrepancy  may  be  explained  by  a  fact,  which 
Mr.  Norman  stated  in  a  very  practical  paper  read  before  the  North  London 
Medical  Society ;  some  other  part,  perhaps,  by  a  statement  of  Dr.  Frazer's, 
that  he  has  seen  a  large  quantity  of  nutmegs,  which  had  been  subjected  to 
distillation,  sent  to  be  used  as  cubebs!  Mr.  Norman  brought  forward 
some  very  strong  facts  to  show  that  the  action  of  the  pepper,  when  freshly 
ground,  is  much  more  certain  and  potent  than  when  it  has  been  kept  some 
time.  He,  however,  admitted  that  even  thus  used  it  often  fails.  To  this 
difficulty  must  be  added  an  objection  made  against  copaiba,  viz.,  that  it  is 
utterly  impossible  to  separate,  at  the  outset  of  the  treatment,  those  cases  in  which 
it  is  likely  to  be  of  service  from  those  in  which  it  is  almost  certain  to  fail ;  and 
hence,  that  a  surgeon  treating  twenty  cases  with  this  drug,  cannot  tell 
beforehand  how  many  out  of  this  number  he  is  even  likely  to  cure,  leaving 
aside  any  question  of  certainty. 

Cubebs  is  said  in  some  cases  to  have  exasperated  the  symptoms  of  gon- 
orrhoea ;  but  this  I  think  is  doubtful,  and  most  probably  arose  from  its 
having  exercised  no  control  over  the  disease  it  was  given  for.  I  am  much 
inclined  to  doubt  if  any  medicine  can  aggravate  the  disease,  except  in  fail- 
ing to  cure  it.  Behrend,  in  his  "  Syphilidologie,"  says  cubebs  does  not  suit 
an  irritable  stomach — an  announcement  I  can  easily  credit.  There  is,  how- 
ever, good  reason  for  believing  that  in  some  cases  large  doses  have  set  up 
considerable  irritation,  if  not  actual  inflammation,  in  the  prostate  and  blad- 
der. 

It  occasionally  cures  with  marvellous  rapidity,  but  these  cases  occur  in 
those  happily  constituted  persons  who  throw  off  disorders  with  extreme 
ease,  and  who  are  freed  from  any  severe  gonorrhoea  by  very  simple  reme- 
dies. 

1  Transactions  of  the  Medico-Chirurgical  Society,  vol.  xii.,  p.  99. 
*  Edinburgh  Medical  and  Surgical  Journal,  p.  52.    1858. 
1  Elements  of  Materia  Medica,  vol.  ii. ,  p.  756.     1840. 


TEEATME1STT.  81 

"When  the  surgeon  has  decided  to  prescribe  cubebs,  it  should,  I  think, 
always  be  ordered  in  teaspoonful  doses  of  the  fresh-around  pepper  two  or 
three  times  a  day.  Mr.  Squire  suggests  moistened  wafer-paper  as  a  vehicle. 
The  paper  may  be  flavored  with  essential  oil  of  almonds.  The  powder  is 
made  into  a  paste  with  syrup  of  ginger,  and  then  laid  upon  the  paper,  which 
is  folded  over  it.  The  patient  takes  a  mouthful  of  water,  and  then  tosses 
the  bolus  down  his  throat.  It  is  said  in  the  Pharmaceutical  Journal,1  that 
"  it  is  surprising  how  easily  patients  acquire  the  tact  of  bolting  these  bol- 
uses, without  any  convulsive  action  of  the  muscles  of  the  throat."  The  sur- 
prising part  of  the  matter  to  me  is  that  they  ever  acquire  the  power  of  doing 
so,  and  indeed  that  they  do  not  choke  themselves  at  the  first  attempt.  I 
should  have  thought  that  it  almost  equalled  the  feat  of  swallowing  a  clasp- 
knife. 

The  practice  of  prescribing  copaiba  and  cubebs  together,  when  one  or 
both  have  failed  separately  to  cure  the  gonorrhoea,  is,  I  believe,  a  useless 
experiment.  After  giving  my  best  attention  to  the  facts,  I  can  only  conclude 
that  all  the  instances  in  which  this  combination  is  said  to  have  effected  a 
cure,  were  simply  cases  in  which  the  separate  ingredients  had  been  of  de- 
fective quality,  or  taken  irregularly,  or  in  too  small  doses,  or  where  their 
action  had  not  been  properly  seconded  ;  and  that  it  is  very  doubtful  whether 
this  combination  possesses  any  curative  power  superior  to  that  of  either 
drug  given  separately. 

3.  Kava-Kava. — The  root  instead  of  the  berry  of  another  pepper,  the  pip- 
er methysticum  or  kava-kava,  is  enthusiastically  recommended2  for  this  com- 
plaint by  M.  Dupouy,  who  does  not  seem  to  be  aware  that  it  has  long  been 
known,  and  that  the  disgusting  mode  of  procuring  an  intoxicating  drink  from 
it,  practised  by  the  old  women  at  Otaheite,  where  the  "  enchantresses  of  gay 
Licoo,"  when  age  has  robbed  the  charming  young  creatures  of  their  teeth, 
are  specially  told  off  for  this  purpose,  has  been  already  quite  sufficiently  de- 
scribed. The  tree  is  a  native  of  Oceania,  and  is  found  in  the  Society  Islands, 
Samoa,  Wallis  Island,  etc.  The  fresh  root  when  chewed  is  bitter,  astrin- 
gent, and  sialagogue.  It  is  the  dry  root  which  is  used  for  gonorrhoea,  and 
the  method  of  employing  it  at  Tahiti  is  as  follows  :  Four  or  five  grammes 
of  the  root  are  macerated  in  a  thousand  grammes  of  water  for  five  minutes, 
and  this  monstruous  potion  is  taken  daily  in  two  doses,  indifferently  before 
or  after  food,  till  a  cure  is  effected.  In  twenty  minutes  after  the  first  dose 
a  pressing  desire  to  make  water  is  felt,  which  most  likely  the  reader  will 
consider  a  very  probable  result  indeed.  However,  this  is  soon  compensated 
for,  as  any  pain  previously  felt  during  micturition  disappears  and  is  replaced 
by  a  sense  of  comfort,  while  urine  charged  with  deposit  and  coloring  mat- 
ter becomes  clear.  Ten  or  twelve  days  of  this  treatment  always  effected  a 

'Vol.  v.,  p.  503. 

2  Journal  de  Therapeutique.     Quoted  in  the  Gazette  Medicale  de  Paris,  p.  166. 
1876. 

fi 


82  ON    GONORRHCEA. 

cure  in  the  cases  which  he  saw.  M.  Dupouy  therefore  considers  the  kava- 
kava  a  powerful  diurftic  and  a  remedy  "  par  excellence  "  for  gonorrhoea. 
It  does  not  derange  the  digestive  organs,  induces  neither  diarrhoea  nor 
constipation,  is  taken  with  pleasure  by  those  who  have  a  delicate  stomach, 
stimulates  appetite  and  does  not  create  any  distaste. 

Such  is  the  flattering  side  of  the  question,  and  but  too  frequently  the 
only  side  presented  to  us  ;  it  may  therefore  perhaps  be  as  well  to  take  an- 
other, which  is  to  the  effect  that  the  kava-kava  does  not  possess  a  particle  of 
the  curative  virtue  ascribed  to  it,  and  that  the  story  seems  fated  to  figure 
some  day  in  the  long  list  of  self-deceptions.  Herr  Zeissl  administered  the 
drug  carefully  to  twenty  patients,  in  not  one  of  whom  did  it  produce  the 
slightest  change  for  the  better  !  1 

4.  Turpentine. — In  a  scientifically  arranged  treatise,  turpentine  ought 
perhaps  to  have  followed  copaiba,  and  not  cubebs,  but  as  I  aim  only  at  be- 
ing useful,  I  trust  to  stand  excused  for  placing  together  the  two  remedies 
most  frequently  used  and  most  frequently  combined. 

Turpentine  was,  however,  in  its  time  quite  as  fashionable  a  remedy  for 
gonorrhoea  as  cubebs  at  the  present  day.  It  seems  clearly  to  possess  a 
certain  amount  of  control  over  the  discharge  in  the  later  stage,  when  it 
has  become  partly  mucous  but  is  still  profuse.  Some  substances  of  this 
nature,  such  as  the  resin  of  the  spruce  fir,  act  very  beneficially  when  the 
inflammation  of  gonorrhoea  has  extended  to  the  neck  of  the  bladder,  and 
even  to  the  body  of  this  viscus.  In  all  other  stages  of  gonorrhoea,  and 
particularly  when  it  is  acute,  every  preparation  of  turpentine  that  I  have 
seen  tried  has  always  appeared  to  me  inert. 

In  large  doses  it  may  occasion  sickness  or  nausea,  but  I  believe  it  is 
quite  unnecessary  to  use  it  in  such  a  way,  and  that  all  the  benefit  likely  to 
accrue  from  its  use  will  be  obtained  by  giving  it  in  moderate  quantity. 
Perhaps  Chian  turpentine  will  be  found  as  useful  as  any.  It  should  be 
simply  aUowed  to  dry  to  the  consistence  of  an  ordinary  extract ;  it  is  then 
rolled  in  magnesia  and  divided  into  five-grain  pills,  two,  three,  or  four  of 
which  may  be  taken  twice  a  day.  Care,  however,  should  be  taken  to 
secure  genuine  Chian  (or  Cyprus)  turpentine,  the  resin  of  the  turpentine 
pistachia  (Pistachia  Terebinthus),  as  the  coniferous  turpentines  are  only 
too  often  substituted  for  it. 

Kemedies  of  this  kind  have  been  tried  by  means  of  inhalation,  and  I 
suppose  the  result  has  been  about  as  complete  a  failure  as  could  well  be 
imagined.  Two  cases  of  gonorrhoea  treated  in  this  way  are  mentioned 
in  the  Wiener  medizinische  Zeitung*  one  with  rectified  turpentine,  a  cure 
ensuing  in  twenty-five  days,  and  one  with  ethereal  oil  of  pine,  which  an- 
swered so  badly  that  at  the  end  of  eighteen  days  the  patient  was  obliged 
to  fall  back  upon  astringent  injections.  The  remedy  is  therefore  useless, 

1  Wiener  medizinische  Wochenschrift,  S.  1023.    1879.  2 1873,  S.  253. 


TREATMENT.  83 

and  any  farther  attempts  in  this  direction  would  amount  to  inflicting  need- 
less suffering. 

5.  Ngan  Plang.1 — Some  years  ago  my  attention  was  called  to  the  value  of 
this  medicine  in  gonorrhoea,  and  half  a  pint  was  sent  to  me  for  the  purpose 
of  making  some  trials  with.     It  is  a  reddish-colored  fluid,  about  the  con- 
sistence of  syrup, 'and  of  a  warm  balsamic  taste,  reminding  one  of  a  deli- 
cately flavored  kind  of  copaiba  or  turpentine.     It  is,  I  believe,  for  I  have 
not  been  able  to  obtain  such  full  and  precise  information  about  it  as  I 
could  have  wished,  found  only  in  Java,  where  it  is  considered  a  specific  for 
gonorrhoea.     It  is  taken  in  doses  of  a  teaspoonful  two  or  three  times  a 
day,  no  other  means  being  used.     No  restriction  as  to  diet,  etc.,  is  im- 
posed on  those  taking  it.     I  gave  it  in  four  cases,  in  drachm  doses  two  or 
three  times  a  day.     All  the  patients  assured  me  that  they  took  the  medi- 
cine with  the  greatest  regularity,  and  I  have  every  reason  to  believe  that 
they  would  only  state  the  exact  truth.     The  report  in  every  case  was  that 
they  did  not  notice  any  particular  effect  from  the  remedy.     It  was  not  un- 
pleasant, they  said,  to  take,  and  agreed  very  well  with  them  ;  beyond  that 
they  had  nothing  to  relate.     I  examined  the  patients  nearly  every  day 
while  they  were  using  it,  but  did  not  notice  any  appreciable  action  on  the 
gonorrhoea. 

I  have  since  then  repeatedly  inquired  of  friends  and  patients  who  had 
been  in  the  East,  as  to  whether  they  had  ever  heard  of  this  drug,  but 
never  met  with  any  person  to  whom  it  was  known.  I  have  also  examined 
the  medical  journals  pretty  diligently  with  the  same  view,  but  with  equal 
want  of  success. 

6.  Matico. — As  this  drug  contains  a  terebinthinate  oil,  it  may  very  prop- 
erly find  a  place  here.     I  have  been  given  to  understand  that  it  is  used 
now  in  many  cases  of  gonorrhoea,  but  that  it  is  the  resin  which  is  em- 
ployed, and  in  the  form  of  capsules.     My  inquiries  on  this  point,  however, 
elicited  no  reliable  information  as  to  whether  this  is  the  fact,  or  how  much 
of  this  ingredient  is  contained  in  each  capsule.     No  mention  is  made  of  a 
resin  in  the  Pharmacopoeia,  or  Mr.  Squire's  "  Companion."    M.  Diday  tells  us 
that  druggists  sometimes  very  judiciously  associate  it  with  copaiba,   to 
which  addition  he  ascribes  the  only  power  it  possesses. 

I  have  only  had  one  opportunity  of  trying  these  capsules,  and  there- 
fore can  say  but  little  about  them.  In  the  case  I  allude  to,  the  patient,  a 
delicate-looking,  thinly  built  man,  suffering  under  a  moderately  profuse 
discharge,  attended  with  some  chordee  and  irritability  of  the  bladder,  in- 
formed me  that  he  had  had  gonorrhoea  once  previously,  and  that  then  the 
disease,  after  long  resisting  other  remedies,  was  promptly  subdued  by  tak- 
ing twelve  matico  capsules  daily.  Consequently  I  thought  this  a  very 
suitable  case  for  testing  the  remedy,  and  advised  him  to  take  the  same 
number  of  capsules.  He  accordingly  procured  some,  which  he  identified 

1  Pronounced  Ne-an-Plang. 


84  ON    GONORRHOEA. 

as  similar  to  those  used  on  the  previous  occasion,  and  took  them  at  the 
same  rate.  At  the  end  of  a  few  days,  the  discharge  being  in  precisely  the 
same  state  and  his  health  being  quite  unaffected  by  the  medicine,  I  sug- 
gested raising  the  dose,  and  he  at  once  began  taking  eighteen  capsules 
a  day.  Four  or  five  days  later  he  reported  satisfactory  progress,  and  then, 
two  or  three  days  after  that,  told  me  that  he  was  no  better  than  before  he 
took  the  matico,  having  thus,  in  a  very  short  time,  twice  changed  his  mind 
about  the  action  of  the  medicine.  For  my  part,  although  I  saw  the  case 
almost  daily,  I  could  not  observe  that  the  remedy  exerted  any  influence 
over  the  running. 

I  believe  the  patient  did  everything  in  his  power  to  second  the  opera- 
tion of  the  matico ;  indeed  he  was  most  anxious  to  get  well,  the  continu- 
ance of  his  malady  being  for  him  a  very  serious  matter ;  at  the  same  time 
I  am  doubtful  whether  the  remedy  received  a  fair  trial,  as  I  am  not  quite 
clear  that  some  degree  of  contraction  was  not  springing  up  at  the  time  ; 
indeed  a  certain  amount  of  it  was  found  later  on,  and  the  case  will  be  sub- 
sequently related  under  the  head  of  cases  complicated  by  stricture. 

7.  Oil  of  Santal-wood. — We  are  indebted  to  Dr.  Henderson,  of  Glasgow, 
fora  knowledge  of  this  drug.1  He  gives  it  in  doses  of  twenty  to  forty 
minims,  and  often  notices  a  most  marked  suppression  of  the  discharge 
within  forty-eight  hours.  He  recommends  it  as  a  pleasant  medicine,  not 
liable  to  cause  sickness  or  to  communicate  any  odor  to  the  urine.  Shortly 
after  Dr.  Henderson's  communications  some  other  reports  appeared  about 
the  oil,  almost  if  not  quite  as  favorable  as  his  own.  A  very  natural  result 
of  this  was  that  it  came  into  general  use,  and  though  the  demand  for  it  has 
greatly  lessened,  yet  I  am  assured  there  are  many  persons  whose  faith  in  it 
remains  unshaken ;  and  I  need  scarcely  say  that  it  figures  in  the  prepara- 
tion made  by  Messrs.  Hewlett,  the  liquor  santali  flavi,  of  which  great  suc- 
cess is  reported.  Many  of  those  gentlemen  who  have  prescribed  it  largely 
consider  it  quite  as  efficacious  as  copaiba,  and  infinitely  more  pleasant  both 
as  to  taste  and  operation.  We  have  the  authority  of  Dr.  Otis  in  its  favor. 
Dr.  Atkinson,  formerly  house  surgeon  of  St.  Bartholomew's  Hospital,  Chat- 
ham, who  was  one  of  the  first  to  employ  it  in  England,  and  who  watched 
its  action  with  great  care,  was  kind  enough,  in  reply  to  some  questions,  to 
inform  me  that  he  had  seldom  found  it  fail  in  acute  and  subacute  cases  ; 
that  pain  in  micturition  generally  stops  after  the  third  or  fourth  dose, 
whilst  the  discharge  itself  usually  ceases  after  the  third  day.  Dr.  Atkinson, 
however,  thinks  it  as  well  to  continue  the  oil  up  to  the  seventh  or  eighth 
day,  so  as  to  guard  against  the  possibility  of  a  return.  With  the  excep- 
tion of  very  slight  griping  pains  about  the  bladder,  he  has  never  known 
any  unpleasant  results  from  the  use  of  this  remedy.  The  dose  he  generally 

1  Glasgow  Medical  Journal,   p.  70, 1865  ;  and  Medical  Times  and  Gazette,  vol.  i. ,  p. 
571.   1865. 


TREATMENT.  85 

gives  is  from  twenty  to  thirty  minims  in  a  little  mucilage  and  cinnamon- 
water  three  times  daily. 

A  Glasgow  correspondent  of  the  Practitioner, l  however,  has  questioned 
its  possessing  any  curative  power,  the  remedy  having  failed  not  only  in 
his  hands,  but  in  those  of  other  practitioners,  while  its  other  good  quali- 
ties have  been  equally  contested.  M.  Diday,  in  his  new  work,  ranks  the 
essence  of  yellow  sandal,  which  I  suppose  is  the  same  substance,  among 
the  futilities,  parmi  les  insignifiants  ;  M.  Panas  also  observed  '  that  an  odor 
was  communicated  to  the  urine,  and  that  though  the  oil  rapidly  lessened 
the  running,  yet  in  a  certain  number  of  cases  recourse  to  further  measures 
was  necessary  ;  and  Dr.  Purdon  found  that,  so  far  from  occasioning  little 
nausea  and  having  little  smell,  as  stated  by  Dr.  Henderson,  he  had  in  many 
instances  to  discontinue  its  use  on  account  of  the  nausea  it  brought  on, 
and  that  the  odor  was  extremely  well  marked,  remaining  in  the  breath  and 
on  the  hands  for  hours  after  being  washed,  and  being  evident  in  the  urine. 

These  objections,  however,  did  not  deter  Mr.  Robert  Park  from  espous- 
ing the  cause  of  the  oil,  which  he  has  done  in  a  very  able  and  temperate 
article,3  showing  a  sound  knowledge  of  his  subject.  The  oil,  he  tells  us, 
was  first  introduced  extensively  into  practice  by  the  late  Dr.  Milner,  of  Glas- 
gow. It  is  in  the  case  of  full  plethoric  subjects,  with  thick  purulent  dis- 
charge from  the  urethra,  that  its  specific  power  is  so  strongly  marked  ;  in 
such  cases  it  often  effects  a  cure  in  from  two  to  five  days.  He  gives  five 
minims  every  four  hours,  and  says  that  larger  doses  are  superfluous  and 
even  dangerous.  If  this  view  be  well  founded,  we  must  conclude  that  other 
authorities  are  in  error  about  the  doses  and  properties  of  the  oil,  that  it  is 
perhaps  only  suited  to  particular  cases,  and  that  our  knowledge  of  the  sub- 
ject must  become  complete  before  we  can  use  it  in  a  reliable  way.  He  now 
says 4  it  does  not  cure  the  urethritis,  but  restrains  the  running  at  once,  very 
frequently  stopping  it  in  forty-eight  hours,  whereas  I  have  never  once  been 
able  to  effect  any  such  rapid  change.  Even  then  it  must,  he  tells  us,  be 
continued  "  quite  a  fortnight  after  entire  cessation  of  the  discharge,  to 
make  sure  the  latter  does  not  return." 

It  is  very  probable  that  some  part  of  this  discrepancy  might  be  explain- 
ed by  a  fact  with  which  these  gentlemen  do  not  seem  to  have  been  ac- 
quainted. The  fact  is,  that  oil  of  santal-wood  is  so  extensively  adulterated 
with  balsam  of  copaiba  and  castor-oil,  that  the  genuine  fluid  forms  in  many 
cases  but  a  very  small  part  of  what  is  administered.  Some  years  ago  I  was 
assured  by  a  gentleman  on  whose  opinion  I  can  quite  rely,  and  who  was 
kind  enough  to  take  a  great  deal  of  pains  in  order  to  procure  me  the  infor- 
mation I  required,  that  there  was  not  a  pint  of  pure  santal-wood  oil  to  be 
bought  in  the  market  at  any  price,  and  yet  the  supply  to  the  retail  houses 
was  so  regular  and  large  as  to  seem  practically  inexhaustible  ;  a  fact  which 

1  Vol.  iii.,  p.  196.  -  Gazette  Hebdomadaire,  p.  843.    1865. 

3 Practitioner,  vol.  ii.,p.  266.    1869.  "Ibid.,  vol.  ii.,  p.  440.    1881. 


86  ON    GONOKRHffiA. 

he  partly  explained  by  adding,  that  once,  when  supplying  the  oil  direct 
from  the  still,  he  had  been  asked  how  much  copaiba  and  castor-oil  it  would 
require  to  bring  it  up  to  the  commercial  standard. 

The  pure  oil  of  santal-wood  is  of  a  light  but  clear  yellow,  without  the 
least  tinge  of  brown,  almost  exactly  the  same  hue  as  pure,  fresh,  sweet 
almond-oil ;  whereas  that  generally  sold  has  a  tint  approaching  the  color 
of  copaiba,  and  a  look  like  mastic  varnish  which  has  lost  some  of  its  trans- 
parency ;  but  to  some  extent  the  color  of  the  oil  differs  according  to  the 
district  from  whence  the  wood  comes  and  the  age  of  the  tree.  The  best 
oil  has  a  slight  smell  of  copaiba,  a  fact,  I  am  told,  from  which  the  first  hint 
of  adulteration  was  taken.  The  pure  oil  is  intensely  strong,  and  so  acrid 
in  taste  that  I  can  only  compare  it  to  croton-oil.  Though  I  have  prescribed 
the  oil  as  usually  sold,  I  have  not  made  many  experiments  with  it,  confining 
myself,  as  far  as  I  well  could,  to  that  procured  from  Messrs.  Pears,  on  which 
I  felt  assured  complete  reliance  might  be  placed,  and  which  they  sell,  I  be- 
lieve, pure  as  it  drops  from  the  still,  in  sealed  bottles. 

Most  of  the  patients  for  whom  I  prescribed  genuine  oil  have  assured  me 
that  the  doses  ordered,  from  twelve  to  twenty  minims,  were  as  much  as  they 
could  bear.  One  gentleman  took  thirty-five  minims  three  times  a  day,  but 
he  was  peculiarly  insensible  to  the  action  of  all  the  medicines  I  gave  him,  and 
even  he  had  to  discontinue  the  remedy  at  the  end  of  two  or  three  days,  as 
he  found  it  was  inducing  nausea.  Judging  from  the  effect  which  the  oil 
produced  on  my  own  mouth,  I  should  have  thought  it  impossible  for  any 
one  to  support  even  such  a  quantity  as  thirty -five  minims. 

As  to  Dr.  Henderson's  statement,  that  it  has  a  very  slight  smell,  I  cannot 
understand  it.  I  kept  a  specimen  of  the  pure  oil  for  several  months,  and 
yet  the  smell,  when  the  fluid  was  even  slightly  warmed,  was  exceedingly 
pungent  and  most  characteristic ;  in  fact  it  seemed  to  overpower  that  of 
any  material  the  oil  may  be  adulterated  with.  With  regard  to  the  cures 
said  to  have  been  effected  by  means  of  this  oil  given  in  combination  with 
liquor  potassse,  I  may  say  that  the  latter  fluid,  given  in  moderate  doses  in 
conjunction  with  very  small  quantities  of  balsam  of  copaiba,  or  mucilage  of 
acacia,  linseed-tea,  veal-broth,  or  any  bitter  infusion,  will  cure  a  great  many 
cases  of  gonorrhoea — a  fact  which  I  briefly  pointed  out  many  years  ago  in 
the  first  edition  of  this  work. 

Some  of  my  first  trials  with  the  oil  were  encouraging.  Given  as  below  ' 
it  seemed  to  agree  very  well  with  the  patients,  who  found  it  rather  stom- 
achic than  otherwise,  and  it  certainly  appeared  to  remove  slight  discharges, 
particularly  when  injections  were  also  used.  But  even  in  some  of  them  it 
did  not  succeed  as  I  could  have  wished,  and  in  the  more  severe  forms  of 
the  affection  I  could  not  observe  that  it  exerted  any  appreciable  action. 

1  B.  Olei  santali,  3  j.,  Ovi  vitelli,  q.s.  ;  tere  bene  et  adde,  Spir.  setheris  nitrosi,  3  ij., 
Syrupi  flor.  aurant.  I  iv. ,  Aquae  cinnam.  ad  5  vj.  M.  Cochlearia  ampla  duo  ter  quot- 
idie  sumenda. 


TREATMENT.  87 

Certainly  at  the  end  of  six,  eight,  and  even  ten  days,  the  discharge  had  not 
ceased.  My  faith  in  its  virtues  has  not  improved  on  acquaintance;  on  the  con- 
trary, farther  experiment  has  only  shown  that  the  skepticism  set  up  by  the 
first  trials  was  justifiable.  In  all,  taking  those  cases  which  I  could  watch, 
I  have  prescribed  the  two  kinds,  the  pure  and  the  oil  of  commerce,  for  twen- 
ty-two patients  suffering  from  the  acute  f orm  without  effecting  a  single  cure. 
It  may  be  that  I  omitted  some  precaution  which  I  ought  to  have  taken,  or 
gave  the  oil  in  too  small  doses,  but  if  I  am  to  rely  upon  my  own  experience, 
and  pass  an  opinion,  it  must  be  that  the  oil  is  not  possessed  of  as  much 
curative  power  as  balsam  of  copaiba.  At  the  same  time  I  think  it  a  valu- 
able addition  to  the  Pharmacopoeia  as  a  remedy  for  bronchitis,  in  which 
complaint  I  have  repeatedly  used  it,  being  more  agreeable  than  copaiba  and 
quite  as  efficacious,  if  not  more  so. 

8.  Gurgun  or  Gurghun.     TJie  Gurgina  Balsam  or  Wood-oil. — This  rem- 
edy,   the   product   of   the   Dipterocarpus   turbinatum,   was   also    recom- 
mended by  Dr.  Henderson.1     It  is  a  medicine  of  the  same  class  as  the  oil 
of  santal-wood.     Dr.  Henderson  experimented  with  it  for  a  long  time,  and 
then,  having  exhausted  his  stock,  was   obliged  to   suspend   operations. 
He,  however,  only  used  it  in  cases  where  copaiba  had  been  tried  and  had 
failed.     He  gave  it  in  large  doses,   such  as  a  teaspoonful  two  or  three 
times  a  day,  and  found  it  in  every  case  successful  within  a  week.     I  have 
no  practical  experience  of    its  action,  and  I  have  not  been  able  to  learn 
whether  any  trials,  of  such  a  nature  as  to  furnish  the  means  of  arriving  at 
any  reliable  opinion,  have  been  made  of  its  power  over  gonorrhoea,  except 
by  the  gentleman  just  alluded  to. 

9.  Erigeron  Oil. — Some  years  ago,  Dr.  J.  S.  Prettyman,  in  a  communi- 
cation to  the  American  Journal  of  the  Medical  Sciences,3  stated  that  he  had 
tried  the  oil  of  erigeron  in  about  fifty  cases  of  gonorrhoea,  and  found  that 
it  arrests  the  discharge  in  about  seventy-two  hours,  and  effects  a  cure  in 
from  six  to  eight  days.     He  did  not,  however,  recommend  it  as  a  specific, 
though  it  seems  from  such  testimony  quite  as  much  entitled  to  the  name 
as  copaiba. 

The  patients  took  the  medicine  as  follows.  A  gill  of  an  aperient  infu- 
sion of  senna  and  jalap,  with  some  aromatic,  was  ordered,  and  so  soon  as 
it  operated,  ten  drops  of  the  oil  on  sugar  were  taken.  This  was  followed 
up  three  hours  later  by  a  full  dose  of  spirit  of  nitric  ether  in  infusion  of 
marshmallow.  Then,  three  hours  after  this,  or  six  hours  from  the  taking 
of  the  first  dose  of  oil,  a  second  dose  of  oil  was  given,  followed  in  its  turn 
by  a  second  dose  of  the  nitric  ether  mixture,  and  so  on.  Dr.  Prettyman 
states  that  he  had  only  so  far  used  the  oil  reputed  to  be  obtained  from  the 
Erigeron  canadense,  but  that  he  thought  that  of  E.  philadelphicum  must  be 
equal  if  not  superior.  The  paper  is  very  short,  and  contains  no  account 

1  Glasgow  Medical  Journal,  p.  71.  1865.  'Vol.  lii. 


88  ON    GONORRHOEA. 

of  the  history,  taste,  properties,  etc.,  of  the  oil.  I  suppose  most  persons 
who  have  read  the  account  would  imagine  that  this  substance  really  pos- 
sesses some  control  over  gonorrhoea,  yet  it  so  entirely  failed  in  the  hands 
of  Professor  Stein,  of  New  York,  who  seems  to  have  given  it  a  fair  trial,1 
that  it  is  difficult  to  refrain  from  supposing  its  virtues  to  be  imaginary  ; 
while  some  very  briefly  recorded  cases  by  Dr.  Stark 2  show  that  it  is  at 
best  a  highly  unreliable  remedy. 

This  concludes  the  list  of  specific  agents,  so  far  as  my  knowledge  g9es, 
and  I  therefore  pass  on  to  the  consideration  of  some  which  are  more  com- 
prehensive in  their  meaning.  Of  these  the  first  on  the  list  is — 

10.  Antiphlogistic  Means. — Of  these  it  will  not  be  necessary  to  give 
any  lengthened  account,  the  system  having,  as  regards  its  old  complete 
thorough-going  shape,  pretty  well  died  out  in  England,  and  I  believe  en- 
tirely in  Germany  and  America.  In  France,  however,  a  few  vigorous  off- 
shoots from  it  still  survive.  In  at  least  two  reviews  of  former  editions  of 
this  work,  the  opinion  was  expressed  that  all  mention  whatever  of  it  was 
superfluous,  that  the  arguments  employed  against  antiphlogistic  treatment 
were  out  of  date,  a  quarter  of  a  century  behind  the  time.  But  we  know 
what  a  powerful  influence  French  teaching  has  upon  English  practice.  I 
heard  an  eminent  specialist  maintain,  before  a  medical  society,  that  nearly 
everything  we  have  learned  about  venereal  and  urinary  diseases  was  taken 
from  the  French  ;  and  when  we  find  a  master  like  Fournier  recommending, 
in  the  acute  stage  of  gonorrhoea  when  the  symptoms  are  urgent,  fifteen  to 
twenty-five  leeches  to  the  perineum,  repetition  of  this,  with  the  very  sig- 
nificant addition  that  bleeding  from  the  arm  is  only  exceptionally  called 
for,  it  seems  to  me  that  it  can  be  in  no  way  superfluous  to  point  out  the 
inconsistencies  and  inutility  of  the  method.  • 

For  I  think  there  cannot  be  a  doubt  that,  though  indisputably  proved 
by  sound  reasoning  to  be  of  the  first  necessity  for  saving  life  and  subduing 
inflammation,  though  as  universally  accepted  as  any  canon  of  therapeutics 
can  well  be,  it  was  utterly  superfluous  in  the  great  majority  of  cases,  and 
the  indiscriminate  employment  of  it  was  a  mistake.  Possibly  in  some  few 
cases  it  was,  especially  as  regards  the  depleting  process,  what  its  support- 
ers maintained  it  to  be,  a  powerful  means  of  relief.  I  have  been  told  by 
men  in  large  practice,  men  not  at  all  prejudiced  in  favor  of  old  fashions, 
that  the  abandonment  of  the  lancet  in  many  affections,  pneumonia  for  in- 
stance, was  an  error.  Granting  this  to  be  the  case,  I  believe  the  extension 
of  the  system  indiscriminately  to  inflammations  of  all  tissues  was  equally 
an  error,  and  that  the  benefits  supposed  to  arise  from  its  employment  in 
by  far  the  most  of  them  were  purely  imaginary.  Equally  I  believe  that, 
though  the  system  in  the  shape  of  leeching  may  have  now  and  then  been 
useful  in  some  complications  of  gonorrhoea,  such  as  inflammation  of  the 

1  New  York  Journal  of  Medicine,  vol.  i. ,  p.  397.     1870. 
•  Canada  Medical  and  Surgical  Journal,  p.  158.     1877. 


TREATMENT.  89 

prostate,  the  application  of  such  means  to  the  parent  disease  is  uncalled 
for ;  a  mistake,  and  one  which  a  moderate  amount  of  attention  would  avert. 

In  my  early  days  I  saw  both  bleeding  and  leeching  employed  for  gon- 
orrhoea, but  in  no  single  instance  did  I  ever  notice  the  least  benefit  from 
either ;  yet  the  practice  was  continued  to  the  end  of  their  lives  by  men 
who  constantly  saw  such  facts  pass  before  their  eyes.  Nor  do  I  find  that 
the  results,  as  given  by  those  French  medical  men  themselves,  who  adhere 
to  a  system  in  which  antiphlogistic  means  play  a  very  prominent  part,  are 
at  all  encouraging.  Few  authors  have  treated  gonorrhoea  more  energeti- 
cally than  M.  Ricord  ;  I  have  no  means  of  knowing  what  his  present  prac- 
tice is,  but  at  one  time  he  used  leeches,  etc.,  in  a  manner  bordering  closely 
upon  the  heroic  ;  and  yet,  though  it  is  difficult  to  ascertain  what  time  he 
requires  for  the  cure  of  his  patients,  there  is  evidence  enough  to  show  that 
they  often  remain  for  weeks  under  his  antiphlogistic  treatment,  even  when 
seconded  by  rest,  specifics,  injections,  and  cauterization. 

Fournier  and  Melchior  Robert  have  evidently  to  a  great  extent  moulded 
their  treatment  on  that  of  Ricord.  The  former  honestly  admits  that,  face 
to  face  with  a  considerable  number  of  refractory  cases,  his  treatment  an- 
swers very  indifferently.  To  my  mind,  M.  Robert's  account  and  some  of 
his  incidental  allusions  look  very  like  a  history  of  failure.  He  calls  gonor- 
rhoea '  an  "  interminable  maladie  ; "  speaks 2  of  its  interminable,  its  mad- 
dening,3 persistence  ;  of  the  half-cured  state  in  which  the  urethra  remains 
when  "  preceding  blenorrhagias  have  left  it  in  a  leaven  ever  ready  to  fer- 
ment," 4  and  honestly  admits  that,  except  in  a  few  rare  instances,  when  the 
abortive  treatment  avails,  the  disorder  is  only  cured,  in  the  most  fortunate 
cases,  by  the  aid  of  specifics  and  injections,  at  the  end  of  thirty  or  forty  days. 

In  the  cases  I  collected  from  my  own  practice  and  that  of  my  friends, 
the  cures  effected  by  this  mode  did  not  amount  to  more  than  one  in  four, 
and  they  were  both  slow  and  uncertain.  Those  which  yielded  were  mild 
forms  of  the  disease,  and  yet  they  lasted  from  thirteen  to  thirty-seven  days ; 
when  injections  also  were  used,  antiphlogistic  measures  proved  nearly  equal 
to  copaiba,  for  then  out  of  twenty-three  cases  thirteen  were  cured,  the  aver- 
age period  of  treatment  being  twenty-eight  days. 

11.  Purgatives  are  another  favorite  remedy  in  this  disorder.  I  have 
not  been  able  to  find  much  evidence  of  their  curative  power.  Two  or  three 
authors  speak  of  them  as  revulsives,  others  of  their  setting  up  an  internal 
depletion,  phrases  which  sound  to  me  rather  like  the  substitution  of  a 
theory  for  the  statements  of  experience.  What  I  could  make  out  by  ex- 
periment was,  that  a  powerful  purgative  will,  in  some  very  mild  cases,  or 
at  the  beginning  of  the  attack,  most  materially  aid  in  cutting  short  the  dis- 
ease, and  this  is  about  all  it  will  do.  Dr.  Bumstead  says,5  "  We  often  meet 
"with  patients  who  have  treated  themselves  with  low  diet  and  purging  for 

1  Op.  citat.,  p.  70.  slbid.,  p.  80.  3  Ibid.,  p.  81.  4  Ibid.,  p.  117. 

*New  York  Journal  of  Medicine,  vol.  ii.,  p.  210.  1859. 


90 


ON    GONOERHCEA. 


weeks,  and  are  no  better  of  their  gonorrhoea."  Durkee  is  strongly  opposed 
to  over-purging.  "Patients,"  he  says,1  "of  their  own  accord  often  pursue 
a  cathartic  plan  for  several  weeks,  and  then  report  that  their  urethral  diffi- 
culty is  as  troublesome  as  at  the  beginning."  Mr.  Whately  relates2  an  in- 
stance in  which  a  purgative  was  repeated  every  day  for  thirty  days  together, 
accompanied  by  a  strict  adherence  to  an  antiphlogistic  plan  of  treatment ; 
and  all  this  was  done  "  without  producing  any  material  alteration  in  the 
complaint,  or  any  considerable  abatement  in  the  inflammatory  symptoms ! " 
Rowley  one s  where  the  patient  was  purged  and  drenched  till  he  looked 
like  "a  dead  corpse."  The  result  of  this  vigorous  treatment  was,  that  pur- 
ple spots  appeared  on  every  part  of  the  body  ;  the  greater  part  of  the  penis 
"dropped  off,"  and  very  soon  afterward  the  patient  died. 

I  now  proceed  to  give  a  table  of  cases  in  which  these  remedies  were 
tested  with  all  the  care  I  could  exert. 

TABLE  TTT 
Cases  treated  wtth  Purgatives. 


K»me. 

Days  pre- 
viously ill. 

Character  of 
the  disease, 
and  previous 
treatment 
when  ascer- 
tained. 

TBEATMENT. 

Date  of  final 
disappearance  of 
the  discharge. 

Medicines. 

Injections. 

1 

W.  D. 

10 

First  clap. 

Strong   purgatives. 

Sulph.zinc.  arg. 

On  the  35th  day 

Pot.  iod.  c.   inf. 

nit. 

a  stricture  was 

rhei.   gum.  acac. 

detected.  Cure 

c.  pot.  nit. 

in  2  months  by 

bougies. 

2 

J.  B. 

3 

.... 

Strong   purgatives 

Nit  of  silver. 

Cure  in  16  dajs. 

3 

W.  H. 

Not  ascer- 

.... 

Ditto. 

Sulph.  of  zinc, 

Cure  in  28  days. 

tained. 

and  occasion- 

ally   nit.     of 

silver. 

4 

J.  S. 

60 

.... 

Pulv.  salin.     Steel 

For  one  month 

Cure  in  47  days. 

and  purgatives. 

none,  then  a 

strong    injec- 

tion   once    a 

week,        and 

used  one  him- 

self occasion- 

ally. 

5 

S.  C. 

Not  ascer- 

.... 

Hyd.     chlor.     and 

None. 

At  the  end  of  15 

tained. 

haust.  cath. 

days    no    im- 

provement. 

6 

H.  H. 

Not  ascer- 

.... 

Ditto,  followed  by 

Injection    only 

At  the  end  of  35 

tained. 

pot.  iod.  c.  inf  us. 

in   the  latter 

days  still  some 

rhei. 

part    of    the 

running. 

<• 

treatment. 

7 

G. 

Not  ascer- 

.... 

Purgatives. 

Ditto. 

At  the  end  of  13 

tained. 

days  still  some 

discharge. 

1  Op.  citat.,  p.  31. 

*  Practical  Observations  on  the  Cure  of  Gonorrhoea  Virulentain  Man,  p.  96. 

3  An  Essay  on  the  Cure  of  the  Gonorrhoea,  p.  13.     1771. 


1801. 


TREATMENT. 


91 


12.  Aperients. — Aided  by  injections,  aperients  will  effect  quite  as  much 
as  the  most  torturing  and  depressing  purgatives ;  and  could  we  but  dis- 
criminate the  cases  at  the  outset,  it  would  in  many  instances  not  be  neces- 
sary to  do  more  than  prescribe  these  two  remedies.  But  this  is  impos- 
sible. It  will  constantly  happen  that  in  very  healthy-looking  persons 
gonorrhoea  becomes  so  severe  or  obstinate  under  this  plan  of  treatment, 
that  other  means  have  to  be  resorted  to  after  a  considerable  waste  of  time 
and  money.  Nay,  it  will  occasionally  happen  that  the  very  same  patient, 
apparently  suffering  from  the  very  same  form  of  the  disease,  can  be  cured 
at  one  time  by  these  simple  remedies,  and  yet  at  another  require  all  our 
resources.  Besides,  this  plan  is  slow  and  uncertain,  even  when  injections 
are  used. 

I  give  below  a  table  of  cases  thus  treated.  I  could  easily  add  to  the 
number,  but  resist  the  temptation,  as  the  returns  agree  so  closely  with 
those  previously  obtained.  And  here  I  may  observe  that  the  reader  will 
probably  enough  object  to  these  tables  as  embarrassing,  superfluous,  and 
difficult  to  carry  in  the  mind.  My  answer  is,  that  they  cannot  be  dis- 
pensed with  ;  that  the  object  in  this  work  is  to  separate,  as  far- as  I  can 
effect  it,  certainties  from  uncertainties.  It  appears  to  me  that  this  is  the 
first  step  on  the  true  road  to  knowledge,  and  that,  without  such  a  method 
there  can  be  no  real  progress.  The  number  of  opinions  and  the  aggregate 
amount  of  experience  may  indeed  increase,  but  such  increase  can  only 
augment  the  difficulties  of  those  who  essay  to  analyze  the  mass  and  extract 
the  truth  from  it.  I  therefore  hold  that  the  only  plan  is  to  reduce  obser- 
vations to  such  a  form  as  will  not  merely  admit  of  their  being  clearly  com- 
prehended and  easily  tested,  but  will  reduce  almost  to  a  minimum  the 
imputation  of  any  vagueness.  "When  observations  are  impartially  digested 
down  into  figures,  we  can  deal  with  them  better  than  in  any  other  form  I 
know  of. 

TABLE  IV. 
Coses  treated  with  Aperients. 


Character  of 

TREATMENT. 

Name. 

Days 
previously 

the  disease, 
and  previous 

Date  of  final  disap- 
pearance of  the 

ill. 

when  ascer- 
tained. 

Medicines. 

Injections. 

discharge. 

R.  M.  K. 

Salines,  carb.   of 

None. 

Left  at  the  expira- 

soda and  pnlv. 

tion  of  13  days, 

jalap. 

in    no    way  im- 

proved. 

A.  R. 

10 

.  •  .  . 

Saline     powder, 

Sulphate       of  Attheendof35days 

consisting     of     zinc   3  i.    to 

the  discharge  dis- 

pulv. rhei.pot. 

oj. 

appeared,  but  re- 

nit.,andsulph. 

turn  ed    imme- 

magnes. 

diately  on   leav- 

ing off  treatment. 

92 


ON    GONORRH(EA. 


Name. 

Days 
pre- 
viously 
10. 

Character  of 
the  disease, 
and  previous 
treatment 
when  ascer- 
tained. 

T»EATMF.NT. 

Date  of  final  disap- 
pearance of  the 
discharge. 

Medicines. 

Injections. 

3 

J.  S. 

30 

Complicated 

Saline  powd.  con- 

Sulphate      of 

Cure    complete  in 

with  rheu- 

sisting of  pulv.  , 

zinc    3  i.    to 

19  days. 

matism. 

rhei.  pot.  nit., 

oj. 

andsulph.mag. 

4 

J.  B. 

21 

.... 

Pulv.      sodae    c. 

None. 

On   the    25th   day 

jalap. 

only  a  slight  gleet 

remaining. 

5 

H.  B. 

Not 

.... 

Pulv.  salin.  pot. 

None. 

On  the  35th  day  the 

ascer- 

nit.   c.     pulv. 

discharge   was 

tained. 

antim. 

still  bad. 

G 

J.  R. 

Ditto. 

.... 

Pulv.  sod.  c.  jal., 

None. 

On   the  34th    day 

pulv.      salin., 

there    was    still 

mist.       salin., 

some    scalding, 

followed      by 

accompanied  by 

tincture    of 

purulent     dis- 

steel. 

charge. 

7 

J.  C. 

Ditto. 

.... 

Pulv.  salin. 

Sulph.  of  zinc. 

At   the   end  of  75 

days    there    was 

some    improve- 

ment.    He    now 

took  no  medicine 

for  35  days,  dur- 

ing which   time 

, 

there  was  no  fur- 

ther alteration  in 

the  disease. 

8 

W.  B. 

.... 

Apparently  Dilute      sulphu- 

None. 

The     discharge 

from   over-     ric    acid     and 

ceased  on  the  3d 

walking.           aperients. 

day. 

9 

.... 

30 

He  had  drunk  Pulv.  salin.    Re-  Sulph.  of  zinc. 

Cured  by  the  35th 

beer,     and     stricted  diet. 

day  ;   the  scald- 

tried to  cure 

ing  ceased  on  the 

himself 

6th  day. 

with  salts. 

10 

A.  D. 

30 

Be       com  -  Pulv.  salin. 

Ditto. 

By  the  21st  day  the 

plained    of 

scalding     had 

the  scalding 

nearly    ceased, 

being   very 

and  by  the  25th 

severe. 

the  discharge  was 

gone. 

11 

.... 

3 

N1  o  t     very 

Pulv.  sod.  c.  jal.  Lotio     saturn. 

On   the    30th   day 

severe. 

No   restriction      to  the  penis,      there    was     still 

in   food    or 

some      purulent 

drink. 

discharge. 

12 

A.  S. 

Not 

.... 

Pulv.  sod.  c.  jal.  ;  Ditto,  followed  On   the   39th    day 

ascer- 

mist, salin.            by  injec.   of 

there    was     still 

tained. 

sulph.      of 

some      purulent 

zinc. 

discharge. 

13 

W.  S. 

« 

.... 

Pulv.  sod.  c.  jal.;  Lotio  saturn.  as 

On    the   61st    day 

pulv.  salin.           an  injection. 

there    was     still 

some      purulent 

discharge. 

14 

A.  S. 

4 

Pulv.  sod.  c.  jal.  Ditto. 

On   the   16th    day 

No   restriction 

almost  all  well. 

in  diet. 

15 

A.  H. 

4 

Ditto. 

Ditto. 

No  improvement  at 

the  end  of  33  days. 

TREATMENT. 


93 


Name. 

Days 
pre- 
viously 
ill. 

Character  of 
the  disease, 
and  previous 
treatment 
when  ascer- 
tained. 

TREATMENT. 

Date  of  final  disap- 
pearance of  the 
discharge. 

Medicines. 

Injections. 

1C 

D.  F. 

6 

Pulv.  sod.  c.  jal. 

Lotio  saturn.  as 

At  the  end  of  14 

No   restriction 

an  injection. 

days   there    was 

in  diet. 

but     little     im- 

• 

provement. 

17 

R.  K. 

90 

He  had  taken 

Pulv.  salin. 

Lotio   saturn., 

Cure  in  78  days. 

copai.    and 

and  after  24 

catechu, 

dayssulph. 

and      used 

zinc. 

injections. 

18 

S.  C. 

7 

.  .  . 

Pulv.  sod.  c.  jal.;  Lotio  saturn. 

On   the  30th   day 

salines. 

the  chordee  had 

ceased,  but  scald- 

ing and  discharge 

were  present. 

19 

E.  S. 

90 

Very  mild. 

Pulv.  salin. 

Sulph.  of  zinc. 

Cure  in  4  days. 

20 

M.  J. 

42 

.... 

Ant.  and  salines.  Ditto. 

Cure  in  30  days. 

21 

B.  B. 

42 

Cubebs    in 

Pulv.  salin.    Not  Sulph.  of  zinc 

On  the   40th    day 

mixture. 

restricted  in 

there  had    been 

diet,    drank 

no  discharge  for 

beer. 

a   week  ;     there 

was    still    some 

smarting  on  mak- 

ing water. 

22 

J.  P. 

270 

Thick    white 

Pulv.      salin. 

Lotio  satnrn. 

On  the    49th    day- 

discharge, 

tinct.  of  steel. 

there    was    still 

no  chordee; 

some  discharge. 

lived  regu- 

larly,   took 

medicine, 

and  no  malt 

liquor. 

23 

W.  C. 

3 

.... 

Pulv.      salin. 

None. 

No  improvement  at 

Drank  beer. 

the    end    of    33 

days. 

24 

A.S.K. 

6 

.... 

Pulv.  salin. 

Sulph.  of  zinc. 

In  12  days  had  di- 

minished    to    a 

gleet,  and  a  few 

injections     com- 

pleted the  cure. 

25     H.  C. 

3 

.... 

Pulv.  salin. 

Ditto. 

Cure  in  43  days. 

26    G.  W. 

24 

.... 

Pulv.  salin.,  fol-  None. 

Cure  in  16  days. 

lowed   by    co- 

paiba and  tur- 

pentine. 

27 

H.  H. 

Not 

Saidtobenon- 

Pulv.  salin.           Sulph.  of  zino. 

Cure  in  12  days. 

ascer- 

venereal. 

tained. 

28 

J.  S. 

60 

Copaiba    and  Pulv.  sod.  c.  jal.  Ditto. 

Cure  in  12  days. 

injections. 

29 

S.  W. 

Not 

Said  to   be  Ditto,  and  tinct.  None. 

On    the   37th   day 

ascer- 

from     a 

ferri  T^.    xx. 

there  was  still  a 

tained. 

strain. 

ter  die. 

slight  gleet,  when 

the  tincture  was 

com  me  n  c  e  d. 

Cure    in  8   days 

more. 

94  ON    GONORRHOEA. 

Here,  then,  with  the  exception  of  four  cases,  one  of  them  (Case  8)  be- 
ing very  likely  not  gonorrhoea  at  all,  where  I  began  injecting  within  the 
first  fortnight,  the  results  were  of  the  most  unsatisfactory  kind.  Many  of 
these  patients  were  as  bad  as  ever  at  the  end  of  thirty,  forty,  or  fifty  days, 
and  the  treatment  had  to  be  exchanged  for  something  more  calculated  to 
effect  a  cure.  A  few  slowly  recovered  ;  and  some,  who  thought  the  disease 
gone  at  the  end  of  a  long  course  of  medicines,  found  it  return  so  soon  as 
ever  they  left  off  treatment.  The  objection  urged  against  copaiba  and 
cubebs  holds  good  here.  When  once  a  case  proves  refractory,  no  further 
benefit  seems  to  arise  either  from  increasing  the  dose  or  persevering  in  the 
use  of  aperients.  Of  this,  practice  affords  us  every  day  the  most  convinc- 
ing proofs ;  and  there  is  perhaps  no  surgeon,  however  limited  his  sphere 
of  observation,  who  has  not  seen  cases  in  which  patients,  attempting  to 
cure  themselves,  had  persevered  for  months  in  the  employment  of  these 
remedies  without  even  materially  relieving  the  disease. 

13.  Diuretics. — The  principal  diuretics  prescribed  in  gonorrhoea  are 
the  spirit  of  nitric  ether,  nitrate  and  acetate  of  potass,  and  liquor  potassse  ; 
though  perhaps  the  latter  ought  only  to  be  classed  exceptionally  under 
this  head,  being  an  antacid.      I  could  never  quite  satisfy  myself  about 
my  own  reasons  for  using  them,  although  I  am  always  glad  to  avail  my- 
self of  their  employment.     A  moderately  increased  action,  however,  of  the 
kidneys  seems  so  generally  to  alleviate  the  disorder,  that  these  remedies 
have  been  admitted  into  almost  every  plan  of  treatment.     The  spirit  of 
nitre  is  perhaps  the  most  unexceptionable  and  pleasant  to  take,  as  it  rarely 
offends  either  the  taste  or  the  stomach,  and  even  when  not  beneficial  never 
acts  injuriously.     As  to  the  nitrate  of  potass  I  must  give  a  more  qualified 
opinion,  and  in  the  section  on  scalding,  in  a  later  chapter  of  this  work,  it 
will  be  seen  that  it  was  given  to  the  extent  of  six  drachms  a  day  without 
producing  the  least  effect  either  on  the  disease  or  scalding.     The  acetate 
is  unquestionably,  I  think,  a  much  more  powerful  remedy  as  an  adjunct. 
It  was  first  introduced,  I  believe,  by  Mr.  Hilton  to  the  notice  of  the  pro- 
fession as  a  remedy  for  gonorrhoea.     Long  previously  I  had  used  it  exten- 
sively, but  I  had  ceased  to  place  any  reliance  upon  it  as  a  specific,  and  this 
is  really  the  only  decision  I  could  arrive  at.     A  close  scrutiny  of  Mr.  Hil- 
ton's cases  will,  so  far  as  such  a  small  number  can  prove  anything,  prove 
this  assertion.     In  the  first  case  the  discharge  ceased  within  sixteen  days  ; 
in  the  second  on  the  eighth  day  ;  while  in  the  third  instance  no  very  ma- 
terial improvement  took  place  for  the  first  fifteen  days,  and  it  required 
thirty-nine  days  to  subdue  the  scalding  and  discharge.     Even  then  the 
cure  was  not  complete.     Liquor  potassse  exerts  a  good  deal  of  control  over 
the  purulent  discharge,  and  in  women  it  often,  combined  with  bitters,  acts 
better  than  remedies  which  prove  more  powerful  in  the  male. 

14.  Alteratives. — This  part  of  the  subject  need  not  detain  us  long,  and 
indeed,    but  for   a    rather  recent   profession    of  faith  in  the  practice,  I 


TREATMENT.  95 

should  not  have  mentioned  it,  as  I  suppose  the  treatment  of  gonorrhoea 
by  means  of  such  medicines  is,  with  a  few  rare  exceptions,  consigned  to 
desuetude  in  this  country.  But  it  is  not  so  in  France.  Mr.  Lee  says  ' 
that  M.  Baumes  and  M.  Lagneau  are  in  the  habit  of  treating  obstinate 
gonorrhoea  by  means  of  a  mercurial  course,  and  with  success,  the  explana- 
tion of  which  is  that  the  gonorrhoea  is  syphilitic.  Nor  do  these  gentlemen 
stand  alone  among  French  practitioners.  Mr.  Lee  himself  clearly  leans  to 
this  belief,  and  considers  that  the  discharge,  from  which  Hunter  inocu- 
lated himself,  was  of  this  nature  and  not  chancre  larve.  Although  I  have 
watched,  with  all  the  care  I  could  bestow,  every  case  bearing  upon  the 
genesis  of  syphilis,  I  have  never  met  with  any  fact  showing  that  it  origin- 
ates except  from  some  recognized  form  of  syphilis  itself.  I  never  saw  the 
plan  tried  but  once  ;  then,  however,  it  was  put  in  force  so  efficiently  that 
the  patient  was  badly  salivated,  but  without  the  gonorrhoea  being  in  the 
least  affected  either  one  way  or  the  other.  Of  the  treatment  with  corrosive 
sublimate  recommended 2  by  Dr.  Brack  I  have  no  experience,  nor  does  it 
seem  desirable  to  try  a  medicine  the  action  of  which  is,  according  to  him, 
attended  by  so  many  drawbacks,  and  which  only  effects  a  cure  in  six  weeks. 

The  iodide  of  potassium,  one  of  the  most  powerful  alteratives  in  proper 
cases,  has  been  repeatedly  made  a  subject  of  discussion,  as  a  remedy  in 
gonorrhoea.  It  is,  however,  inert  for  such  a  purpose,  except  in  so  far  as 
the  potassium  may  act  in  the  same  way  as  the  liquor  potassse  does  ;  and 
any  benefit  which  arose  during  its  use  was  probably  due,  either  to  this 
cause,  to  some  other  part  of  the  treatment,  or  to  the  natural  tendency 
gonorrhoea  sometimes  shows  to  get  well  of  itself.  In  a  paper  by  Mr.  C. 
Cornwall,  in  the  fifteenth  volume  of  the  Medical  Gazette,  it  will  be  seen 
that  the  author's  success  in  treating  gonorrhoea  in  this  way  amounted  to 
effecting  a  cure  in  thirty-four  days,  which  does  not  show  the  plan  to  be 
unusually  efficient,  I  assume,  however,  that  faith  in  the  virtue  of  the 
iodide,  if  it  ever  really  existed,  is  about  as  extinct  as  that  in  venesection. 

B.  EXTERNAL  APPLICATIONS. — For  the  sake  of  accurate  examination  it  will 
be  best  to  divide  these  into — 1,  cold  applications,  as  ice  and  evaporating 
lotions ;  2,  warm  applications,  as  hot  fomentations,  baths,  etc. ;  and  3, 
sedative  applications.  We  may  thus  ascertain  their  comparative  value,  and 
see  if  there  are  any  fixed  rules  to  guide  us  in  making  use  of  them. 

1.  Cold  Applications. — How  far  cold  evaporating  lotions,  particularly 
when  used  as  they  generally  are,  act  beneficially  in  checking  the  pain  and  in- 
flammation and  in  abating  the  heat  felt  in  the  penis,  and,  indeed,  in  any  in- 
flammation where  a  mucous  membrane  is  implicated,  is  a  question  which 
I  consider  to  be  perfectly  undetermined.  As  yet  there  is  nothing  more 
than  individual  conviction  to  show  that,  were  equal  numbers  of  patients 

1  St.  George's  Hospital  Reports,  vol.  vi. ,  p.  48. 

2  Central  Blatt  fiir  medizinische  Wisseuschaft,  July  1,  1876.      Quoted  in  Medical 
Times  and  Gazette,  vol.  ii.,  p.  163.     1876. 


96 


ON    GONORRHOEA. 


submitted  to  the  same  treatment,  those  who  were  in  addition  treated  with 
cold  applications  would  derive  more  benefit  than  the  others  ;  and  therefore, 
until  some  evidence  of  this  kind  can  be  produced,  the  patient  should  not 
be  subjected  to  the  trouble  and  expense  of  using  them,  and  a  fair  trial 
should  be  made  to  see  if  the  rest  generally  observed  is  not  the  real  source 
of  relief.  My  experience  is  that  they  are  valueless. 

2.  Hot  Applications. — Eicord  condemns  the  hot  bath,  as  Howard  did 
long  previously,1  as  being  liable  to  promote  the  outbreak  or  occasion  the 
reappearance  of  the  discharge.2  Fournier  maintains8  the  same  opinion 
about  any  bath.  With  respect  to  such  a  contingency,  I  would  remark  that 
it  may  be  a  very  possible  occurrence  in  France,  among  the  rather  inflamma- 
ble youths  seen  occasionally  at  the  Hopital  du  Midi,  in  whom  I  should 
say  being  affected  with  gonorrhoea  was  rather  the  normal  state  than  other- 
wise ;  but  so  far  as  my  own  observation  goes,  I  never  saw  or  heard  of  an 
authentic  instance  in  which  hot  baths  exerted  any  prejudicial  influence 
over  the  course  of  gonorrhoea. 

Prior  to  bringing  out  the  first  edition  of  this  work  I  made  a  careful 
series  of  observations,  and  could  not  verify  these  opinions  about  the  injuri- 
ous effect  of  hot  baths  in  a  single  instance.  Blank  forms  were  prepared 
like  the  following,  and  mostly  filled  up  only  from  cases  seen  every  day  ; 
and  it  may  perhaps  save  some  repetition  if  I  state  here,  that  all  the  reme- 
dies, spoken  of  in  this  work  as  having  been  tested  by  myself,  were  experi- 
mented upon  in  this  way. 

Form  for  Calculating  Action  of  Remedies. 


Name  

A.  B. 

Date  

Feels  !  

Better. 

Worse,  etc. 

Discharge  

Lessening. 

Increased. 

Much  the  same. 

Not  lessened. 

Erections  

Troublesome. 

More  troublesome. 

Bladder  

Not  irritable. 

Irritable. 

Urine  

Acid. 

Acidity  lessened. 

Bowels  

Open. 

Costive. 

Tongue  

Clean. 

Foul 

Has  made  the  running  thin- 

Has not  acted. 

Effects  of  injections  

ner  ;  has  acted  freely. 
Moderate   heat  on  making 

Pain  and  burning  for  two 

Effects  of  baths  

water. 
Thought  it  relieved  scald- 

hours after. 
Noticed  no  benefit. 

General   remarks  

ing,  etc. 
Patient  on  the  whole  pro- 

No progress. 

gressing  favorably. 

On  such  data  alone  was  any  reliance  placed,  and  after  destroying  all 
the  incomplete  returns  and  computing  the  results,  it  was  not  found  that 

1  Op.  citat.,  voL  iii.,  p.  61.  "Traite  Pratique,  p.  667. 

3  Nouveau  Dictionnaire,  tome  v. ,  p.  152. 


TEEATMENT.  97 

the  warm  bath  had  ever-  induced  the  slightest  unfavorable  change  in  the 
character  of  the  purulent  discharge.  Experience  continually  tends  to  rat- 
ify the  verdict  first  arrived  at.  I  had  under  rne  a  patient  who  took  quite 
forty  baths,  each  one  at  100°,  and  I  was  not  able  to  detect  the  least  ex- 
asperation of  the  disease. 

But  I  believe  the  bath  to  be  equally  powerless  for  good,  so  far  as  con- 
cerns the  cure  of  the  running.  It  relieves  the  uneasy  sensations  in  the 
urethra,  perineum,  and  testicles  which  often  depress  patients,  especially 
nervous  persons  and  delicate  subjects,  but  I  never  had  reason  to  think 
that  it  shortened  the  duration  of  the  gonorrhoea  by  an  hour.  In  a  report l 
of  the  cases  treated  at  the  Liverpool  workhouse,  it  is  stated  that  the  use 
of  the  warm  bath  has  been  found  to  lessen  the  term  of  gonorrhoea  in  the 
female  ;  Mi*.  Phillips,  who  seems  to  have  been  very  successful  in  his  treat- 
ment, recommends "  that  hot  baths  should  be  used  every  day  for  many 
hours  ;  and  M.  Diday,  who  has  had  good  opportunities  for  knowing  what 
the  success  of  M.  Ricord's  treatment  has  really  been,  and  who  is  as  much 
opposed  to  him  on  this  point  as  one  man  can  well  be  to  another,  carries 
the  practice  almost  as  far  as  Mr.  Phillips.  In  the  irrepressible  stage,  as 
he  calls  it,  he  advises  several  cold  local  baths  a  day.  Should  the  symp- 
toms become  more  pronounced,  the  patient  is  to  take  every  second  even- 
ing a  hot  bath  for  an  hour  and  a  half  at  a  time,  and  two  or  three  times  a 
day  a  lukewarm  local  bath  of  mallow  tea ;  in  still  more  severe  cases  he 
recommends  full-length  baths  daily  for  two  or  three  hours,  and  multiplies 
the  mallow-water  baths.  I  suppose,  then,  these  gentlemen  have  really 
found  some  benefit  from  the  practice,  but  I  can  only  adhere  to  what  I 
have  said  ;  I  admit,  however,  that  it  possesses  one  advantage  ;  it  must 
help  to  relieve  the  ennui  entailed  by  confinement.  A  patient  who  has  to 
spend  two  or  three  hours  daily  in  a  bath,  and  foment  several  times  with 
infusion  of  mallow,  to  take  a  fair  amount  of  medicine  and  two  litres  of 
ptisan,  has  a  nucleus  of  useful  occupation  provided  for  him. 

Contrary  to  the  opinion  of  the  observers  just  mentioned,  I  have  seen 
ground  for  thinking  that  all  the  beneficial  effect  of  the  practice  may  be 
attained  by  a  stay  in  the  bath  of  two  minutes.  Thus  restricted,  I  con- 
stantly employ  it,  particularly  when  the  patient  suffers  much  from  scald- 
ing, or  is  very  sensitive  to  the  action  of  injections.  I  always  recommend 
that  it  should  be  taken  on  an  empty  stomach,  that  the  heat  should  be 
quite  98°  to  100°  Fahr.,  and  that,  if  the  weather  be  very  inclement  and 
the  patient  liable  to  catch  cold,  he  should  have  the  bath  in  the  even- 
ing and  go  straight  home  after  it,  remaining  there  till  next  day. 

But  the  external  application  which  I  like  best,  and  which  is  at  once 
simple  and  useful,  while  it  is  more  attainable  and  less  expensive  than 

1  Medical  Times  and  Gazette,  vol.  ii.,  p.  335.     1861. 

11 A  Treatise  on  the  Urethra,  etc.,  p.  88.     1832. 


98  ON    GONOBEHCEA. 

the  hot  bath,  is  that  of  very  hot  water  to  the  penis.  To  do  any  good, 
however,  the  water  must  be  hot,  not  lukewarm,  and  when  the  case  is 
very  severe,  it  should  be  used  at  such  a  temperature  as  to  make  the  penis 
quite  red.  When  thus  employed,  and  especially  in  the  earlier  stages  of 
the  disease,  the  weight  felt  about  the  testicles  soon  disappears,  the  pain 
on  making  water  and  using  injections  is  soothed,  and  the  glans  and  pre- 
puce lose  their  unhealthy  appearance. 

The  best  plan  of  employing  it  is,  I  think,  the  following :  The  patient 
should  stand  over  a  slop-pail,  holding  a  small  basin  brimful  of  very  hot 
water  in  his  left  hand.  With  the  right  hand  he  should  lift  up  the  penis  by 
the  skin  of  the  upper  part,  and  just  allow  the  lower  surface  to  come  in 
contact  with  the  fluid,  which  must  be  of  such  a  temperature  that  the 
patient  cannot  bear  the  contact  of  it  for  more  than  an  instant  at  a  time. 
When  there  is  uneasiness  about  the  perineum,  he  should  roll  up  a 
piece  of  rag,  flannel  if  possible,  into  a  ball  about  the  size  of  a  walnut, 
tie  this  firmly  to  a  small  piece  of  firewood,  dip  the  ball  in  almost 
boiling  water,  dash  off  the  drops,  and  press  it  against  the  perineum  ; 
or  sit  lightly  down  upon  a  sponge,  just  taken  out  of  boiling  water  and 
put  on  a  cane-bottomed  chair  over  a  slop-pail.  This  practice,  recom- 
mended in  the  earlier  editions  of  this  work,  has  since  then  received  the 
approval  of  Bumstead,1  Durkee,"  and  Lee,3  who  distinctly  state  that  its 
merits  have  not  been  overrated. 

Were  it  no  way  superior  in  its  effects  to  other  applications,  it  would  far 
surpass  them  in  point  of  convenience.  No  smell,  no  mess,  no  cumbersome 
apparatus.  A  piece  of  sponge,  or  a  rag,  and  a  little  hot  water  suffice. 

3.  Sedative  Applications. — This  simplicity,  on  which  its  value  is  in  some 
measure  dependent,  vanishes  the  moment  we  essay  to  increase  its  efficacy, 
by  adding  such  things  as  decoction  of  poppies,  solution  of  opium,  lauda- 
num, etc.  Now  as  one  grain  of  opium  taken  internally  will  really  allay  any 
pain  the  patient  may  feel  more  effectually  than  the  most  elaborate  messes, 
I  should  be  glad  to  know  if  it  is  not  high  time  that  the  employment  of  such 
filthy  concoctions  should  be  summarily  put  down.  Why  will  surgeons  per- 
sist in  trying  again  and  again  some  useless  compound  which  has  failed  a 
thousand  times,  which  can  only  add  to  the  patient's  discomfort,  complicate 
treatment,  and  waste  time ;  which  must  dirty  the  linen,  sheets,  etc.  ?  Is 
it  because  routine,  tradition,  and  authorities  say  that  something  of  this 
kind  must  be  done  ? 

I  wish  some  of  our  physiologists  would  condescend  to  be  useful,  and, 
leaving  off  the  elaborate  experiments  on  dogs  and  cats,  frogs  and  guinea- 
pigs,  would  try  at  least  to  give  us  a  satisfactory  explanation  of  some  mat- 
ters we  know  very  little  of,  such,  for  instance,  as  the  action  of  heat  and  cold 
on  inflamed  surfaces*  All  I  have  been  able  to  make  out  is,  that  in  slight 

1  Op.  citat.,  p.  79.  20p.  citat.,  p.  32.  3Op.  citat.,  p.  207. 


TREATMENT.  99 

inflammations  cold  is  often  more  beneficial  than  heat,  especially  if  the  mere 
outward  surface  is  inflamed ;  but  if  deeper  structures  be  involved,  the  ap- 
plication of  heat  is  more  useful.  Even  here  there  are  contradictions  I  have 
never  seen  explained.  For  instance,  if  the  penis  be  exposed  to  cold  air 
during  the  acute  stage  of  gonorrhoea,  an  exacerbation  is  apt  to  follow,  but 
if  the  organ  be  kept  cool  and  moist,  the  very  opposite  result  ensues  ;  again, 
if  it  be  kept  too  warm,  an  aggravation  of  all  the  symptoms,  especially  of 
the  chordee,  sets  in,  while  the  free  use  of  scalding  hot  water  materially  re- 
lieves all  this,  and  is  invaluable  in  such  complications  as  perineal  abscess 
and  sympathetic  bubo.  Prolonged  application  of  cold  water  to  the  interior 
of  the  urethra  has  undoubtedly  been  of  service  in  gonorrhoea.  Evaporating 
lotions  seem  to  have  no  effect  on  this  disease,  yet,  in  the  wide  field  of  in- 
flammations, I  do  not  know  of  one  that  is  affected  by  any  remedy  so  quickly 
and  certainly  as  orchitis  is  by  these  very  compounds.  In  mammary  abscess 
an  increase  of  pain  is  often  induced  by  exposure  to  cold,  but  if  warmth 
and  moisture  be  applied,  relief  of  the  most  gratifying  kind  is  experienced. 
Heat  and  moisture  have  the  same  soothing  effect  upon  whitlow,  and  under 
their  influence  the  skin  becomes  cooler  and  less  uncomfortable.  Dry  heat, 
such  as  that  of  a  hot  sun,  especially  if  accompanied  by  much  light,  will  often 
rapidly  aggravate  eczema  ;  the  heat  of  a  furnace  is  frequently  far  less  inju- 
rious in  this  disease  than  that  of  a  cold  wind,  and  sometimes  appears  rather 
beneficial.  Some  persons,  suffering  from  eczema  of  the  backs  of  the  hands 
and  wrists  find  that  holding  them  before  a  bright  fire  till  the  skin  is  almost 
scorched  gives  great  relief.  Bathing  an  eczematous  or  erysipelatous  surface 
•with  hot  water  seems  to  me  useless  or  injurious,  whereas  this  applica- 
tion, properly  carried  out,  is  of  much  service  in  many  forms  of  inflamma- 
tion, such  as  croup,  peritonitis,  suppurative  inflammation  of  the  cellular 
tissue,  etc. 

Are  we  to  conclude  that  in  some  men  the  urethra,  rectum,  and  adjacent 
parts  are  acted  on  in  the  same  way  by  cold  as  they  are  in  others  by  heat ; 
or  must  we  believe  that,  in  certain  circumstances,  any  great  departure  in 
either  direction  from  the'  natural  heat  of  the  body  is  attended  with  precisely 
the  same  effect  ?  It  seems  to  me  that  some  of  the  facts  bearing  upon  the 
influence  of  great  change  of  temperature  on  the  urethra  must  demand  one 
of  these  two  solutions.  Thus,  Sir  Benjamin  Brodie  says,1  that  a  gentleman 
of  his  acquaintance,  who  was  subject  to  attacks  of  retention  from  stricture, 
almost  always  began  to  pass  urine  after  a  pint  of  warm  water  had  been 
thrown  up  as  a  clyster.  I  do  not  cite  the  effect  of  the  hot  bath  on  the  same 
state,  because  its  power  has  been  disputed  by  very  good  observers  ;  but  I 
have  seen  the  urethra  yield  to  a  sudden  application  of  almost  boiling  water 
to  the  penis,  after  holding  an  instrument  with  such  firmness  that  I  could 
not  withdraw  it  till  the  water  was  used,  when  it  relaxed  directly.  I  should 


1  Works,  vol.  ii.,  p.  417.    1865. 


100  ON    GONOERHCEA. 

have  thought  that  such  facts  as  these,  which  any  man  of  great  experience 
could  verify  for  himself,  proved  that  heat  does  exert  a  relaxing  influence 
over  spasmodic  tightening  of  the  urethra.  Yet  Mr  Teevan,  in  a  paper  read 
before  the  Harveian  Society,  recommended,  in  spasmodic  retention  of  the 
urine,  that  the  rectum  should  be  plugged  with  ice,  as  a  potent  means  of 
overcoming  the  spasm  ;  and  Sir  Thomas  Watson  says'  that  "in  cases  of  ex- 
ternal inflammation,  sometimes  cold  applications  are  found  to  be  of  use, 
and  sometimes  warm." 

C.  DIRECT  APPLICATIONS.  1.  Injections.  Variety  of  Substances  Used. — 
A  list  of  the  substances  recommended  for  injections  within  the  last  few 
years  would  perhaps  show,  more  strongly  than  anything  I  could  say,  the 
discrepancy  of  opinion  that  prevails  as  to  which  is  the  best.  I  therefore 
give  a  selection :  chloride,  tannate,  and  acetate  of  zinc,  carbolate  of  zinc, 
sulphocarbolate  of  zinc,  sulphate  of  zinc,  curing  as  a  rule  on  the  third  or 
fourth  day,  or  even  sooner  ;  nitrate  of  silver  ;  acetate  of  lead  ;  sulphate  and 
chloride  of  copper ;  the  four  sulphates  (a  combination  of  alum,  zinc,  iron, 
and  copper) ;  iodide  and  potassio-tartrate  of  iron,  iodide  of  iron  in  combi- 
nation with  iron  filings,  tincture  of  sesquichloride  of  iron,  solution  of  per- 
chloride  of  iron,  solution  of  persulphate  of  iron  ;  oxychloride  of  tin  com- 
bined with  phosphate  and  tannate  of  tin  :  trisnitrate  of  bismuth ;  perni- 
trate  of  mercury,  perchloride  of  mercury  ;  chloride  of  soda ;  chlorate  of 
potass,  carbolate  of  potass,  carbolic  acid  and  potass,  permanganate  of 
potass,  which  was  said  to  cure  recent  attacks  of  the  disease  in  from  one  to 
two  days,  and  only  failed  twice  in  64  cases,  being  just  one  day  less  than 
was  requisite  to  effect  a  cure  with  the  chlorate  of  potass,  a  period  subse- 
quently extended  to  twelve  days  for  recent  cases  alone  ;  Condy's  fluid ; 
alum,  tannate  of  alumina,  succeeding,  according  to  one  author,  where  all 
the  usual  injections  had  failed,  and  described  by  another  as  not  more  effi- 
cacious than  other  kinds  of  injections  ;  lime-water,  chloride  of  lime,  bisul- 
phite of  lime  ;  sulphate  of  cadmium,  recommended  as  calming  very  rapidly 
the  acute  period  of  blennorrhagia ;  tincture  of  iodine,  recommended  as 
having  never  failed  during  a  ten  years'  trial ;  nitric  acid  combined  with 
strychnia  ;  sulphurous  acid,  curing  "  in  an  average  of  six  days  ; "  tannin, 
glycerine  of  tannin,  singly  and  combined  with  olive-oil  and  mucilage  ;  gly- 
cerine, combined  with  carbolic  acid  and  tannin  ;  glycerine  and  starch ; 
quinine  and  glycerine ;  matico,  subsequently  denounced  as  the  last  med- 
icament of  the  kind  we  should  have  recourse  to ;  eucalyptus  emulsion, 
used,  along  with  boracic  acid,  to  supplement  soluble  bougies ;  starch ; 
tincture  of  catechu,  solution  of  catechu  in  syrup  of  tolu  ;  tincture  of  rha- 
tany,  extract  of  rhatany  ;  vinum  opii,  tincture  of  opium,  watery  extract  of 
opium,  opium  and  glycerine  ;  decoction  of  poppies  ;  acetate  of  morphia  ; 
belladonna ;  infusion  of  Unseed  ;  chloroform  ;  hydrate  of  chloral,  intro- 


1  Principles  and  Practice  of  Physic,  vol.  i.,  p.  250.    1857. 


TREATMENT.  101 

duced  at  least  two  or  three  times  ;  tincture  of  aloes  ;  hydrastin  ;  leptan- 
drin  ;  red  wine  ;  copaiba,  volatile  oil  of  copaiba,  repeatedly  tried  in  vain  at 
the  recommendation  of  previous  observers,  copaiba  water,  far  more  effica- 
cious than  the  drug  taken  internally  ;  honey  ;  green  tea ;  wine ;  ice-cold 
water,  lukewarm  water,  not  known  to  have  failed  "  where  the  system  was 
adopted  at  the  commencement  of  the  disease  and  followed  throughout," 
warm  water,  recommended  as  curing  in  from  seven  to  nine  days ;  earth  and 
water,  often  curing  in  two  or  three  days  ;  kaolin  and  water ;  and  retention 
of  the  urine  by  means  of  a  kind  of  forceps  (pince).  Though  the  last  can 
scarcely  be  considered  as  an  injection  it  is  intended  to  act  in  the  same 
way.  The  reader  will  be  interested  to  observe  that  substances  of  the  most 
opposite  nature  are  equally  efficacious  in  effecting  the  desired  purpose ; 
curing  the  case  with  fabulous  rapidity,  never  failing,  and  entailing  no  disa- 
greeable results  whatever. 

I  do  not  know  what  he  thinks  of  all  thi^^>ut  to  me  it  is  unsatisfactory 
in  the  highest  degree.  A  series  of  careful  experiments,  prolonged  for  at 
least  sixty  or  seventy  years,  would  be  required  to  examine  with  anything 
like  accuracy  the  comparative  value  of  the  different  substances  here  recom- 
mended. I  say  this  quite  deliberately,  for  it  took  me  more  than  two  years, 
at  a  time  when  I  was  not  overburdened  with  private  practice,  to  satisfy 
myself,  even  imperfectly,  as  to  the  relative  power  of  three  drugs  only, 
namely,  the  sulphate  of  zinc,  acetate  of  zinc,  and  the  nitrate  of  silver. 

It  is  certain  that  there  must,  only  too  often,  have  been  a  serious  mis- 
take as  to  the  real  facts  of  the  case,  and  that  the  substances  so  highly  rec- 
ommended do  not  possess  the  virtues  ascribed  to  them.  How  otherwise 
did  it  happen  that  very  competent  observers  entirely  failed  to  achieve  any 
such  success,  and  that  we  find  such  an  ominous  silence  about  drugs  once 
vaunted  as  specifics  ?  Take  the  history  of  permanganate  of  potass,  for  ex- 
ample. Is  has  been  recommended  by  at  least  five^  or  six  writers,  some  of 
them  quite  in  position  to  judge  of  its  value — Dr.  Rich,  of  Canada ; '  Dr. 
Warden,  of  Haulbowline  Hospital ;  Dr.  Van  Versen,  of  the  United  States 
Army ;  Mr.  Macfie  Campbell,  of  the  Dreadnought  Hospital,  etc.  It  has 
been  extolled  by  one  author  as  curing  in  from  one  to  two  days,  by  another 
as  curing  even  old  cases  of  forty-five  days'  average  duration  in  two  to  ten 
days,2  while  the  failures,  taking  all  the  cases  together,  do  not  amount  to 
more  than  one  in  forty.  It  is  equally  adapted  to  all  cases,  old  or  recent, 
and  possesses,  in  addition,  the  valuable  property  of  being  painless  in  its 
operation,  or  only  occasioning  very  slight  inconvenience  even  in  pretty 
strong  solution. 

Such  being  the  case,  the  permanganate  ought  to  take  rank  as  the  para- 
gon of  remedies  for  gonorrhoea.  Nothing  that  I  have  experimented  with 


1  Edinburgh  Medical  Journal,  September,  1864. 
3  Lancet,  vol.  i.,  p.  73.    1871. 


102  ON   GONORRH(EA. 

approaches  it  in  point  of  efficacy,  and  the  mystery  is  that  a  substance  of 
such  power  has  not  come  into  universal  favor,  and  indeed  banished  at 
once  every  other  drug,  seeing  it  would  be  little  less  than  criminal  to  go 
on  ordering  antiphlogistics  and  specifics,  when  we  possess  a  simple  and 
painless  remedy,  which  puts  an  end  to  the  complaint  in  six  and  thirty 
hours.  But  now  let  us  hear  the  other  side  of  the  question.  According 
to  the  evidence  here  the  permanganate,  so  far  from  being  either  a  pain- 
less remedy  or  a  specific,  is  quite  the  contrary.  Gentlemen  worthy  of 
credit  distinctly  state  that  its  action  on  the  urethra  is  so  strong  as  to  en- 
tirely deter  patients  from  continuing  it.  Used  in  solution  a  little  more 
than  a  fourth  of  the  strength  recommended  as  painless,  it  has  been  found 
to  give  so  much  pain  as  to  necessitate  its  abandonment.  Mr.  Berkeley 
Hill  reports '  that  it  has  been  tried  rather  extensively  at  the  Lock  Hospital, 
and  that  very  few  patients  have  derived  benefit  from  it,  a  statement  cor- 
roborated, as  far  as  one  casein  go,  by  another  contributor  to  the  same 
journal ;  *  while  Dr.  Fessenden  Otis  says 3  he  has  used  this  salt  in  perhaps 
twenty  cases,  with  the  apparent  effect  of  arresting  the  discharge  for  a 
short  time,  but  that  he  has  "  invariably  been  obliged  to  resort  to  other 
means  to  complete  the  cure." 

We  hear  a  great  deal  about  medicine*  being  an  inductive  science,  but 
in  so  far  as  the  therapeutics  of  gonorrhoea  are  concerned,  the  state  of  mat- 
ters which  has  just  been  laid  before  the  reader  is,  in  some  particulars, 
much  more  on  a  level  with  fortune-telling,  or  the  prophecies  in  Moore's 
Almanack,  than  with  science  in  the  proper  sense  of  the  word.  The  reader 
may  think  this  is  going  too  far ;  perhaps  it  is,  but  the  real  authors  of  this 
confusion,  the  medical  men  who  ushered  so  many  useless  things  into 
public  notice  on  such  insufficient  grounds,  first  of  all  went  a  great  deal  too 
far  in  the  opposite  direction ;  and  to  recommend,  in  a  disease  like  gonor- 
rhoea, which  will  often  disappear  under  a  few  cold  water  injections,  a 
remedy  on  the  strength  of  its  having  been  successful  in  some  few  cases,  as 
has  repeatedly  been  done,  looks  to  me  quite  as  haphazard  as  palmistry  or 
weather-wisdom. 

I  do  not  wish  to  convey  the  impression  that  it  is  always  so.  On  the 
contrary,  I  am  anxious  to  bear  testimony  to  the  value  of  many  contribu- 
tions on  this  subject,  and  in  particular  to  the  labors  of  Mr.  de  Meric,  who 
examined  the  action  of  a  remedy  in  140  cases  before  bringing  the  subject 
under  public  notice.4  The  substance  experimented  with  was  the  trisni- 
trate  of  bismuth.  A  special  register  was  kept  of  all  cases,  but  owing  to 
the  neglect  shown  by  the  patients  themselves,  Mr.  de  Meric  was  only  able 
to  obtain  an  account  of  the  results  in  52  instances.  Out  of  the  52  there  were 


'Lancet,  vol.  i.,  p.  570.     1871.  5  Ibid.,  p.  35. 

3  Jsew  York  Journal  of  Medicine,  vol.  i.,  p.  359.    1870. 
4 Lancet,  vol.  i.,  p.  468.     1860. 


TREATMENT.  103 

36  cured,  5  much  better,  and  11  not  improved  at  all.  Even  in  those  cases 
which  were  cured,  the  patients  remained  on  an  average  two-and-twenty 
days  under  treatment,  and  this,  so  far  as  the  injections  were  concerned, 
did  not  begin  till  the  inflammatory  stage  had  subsided.  But  though  the 
result  of  the  trials  was  not  satisfactory,  the  author  deserves  our  praise  for 
the  candor  with  which  he  states  this,  and  the  pains  he  bestowed  on  the 
subject ;  his  paper  is  of  infinitely  more  value  than  the  vague  generalities 
we  often  meet  with  in  books,  or  hasty  encomiums  which  crumble  into 
nothing  at  the  first  touch  of  experiment. 

I  think  I  am  not  going  too  far  when  I  say  that  the  introduction  of 
some  of  these  substances,  such  as  honey,  chloroform,  quinine,  tincture  of 
aloes,  creasote,  et  similia,  must  be  ascribed  to  some  defect  in  the  reasoning 
powers  of  the  persons  who  first  recommended  them,  and  that  any  one  who 
could  expect  to  derive  benefit  from  the  use  of  these  remedies  must  be  in- 
capable of  forming  a  sound  view  of  therapeutics  ;  for  what  property  is 
there  in  any  one  of  them  which  would  lead  us  to  infer  that  it  could  possess 
the  least  power  of  controlling  such  a  disease  as  gonorrhoea,  or  even  modi- 
fying purulent  inflammation  of  any  kind  ?  Only  practical  experience  could 
of  course  prove  they  were  worthless  ;  as  might  have  been  expected  it  did 
so  whenever  these  wretched  tricks  were  put  to  the  test,  but  it  proved  at 
the  same  time  that  they  were  often  most  injurious.  Some  of  the  persons 
injected  with  chloroform  suffered  severe  pain,  amounting,  it  was  said,  even 
to  agony,  for  hours,  followed  by  copious  discharges  of  blood  from  the  urethra, 
and  any  person  who  has  suffered  from  the  contact  of  chloroform  with  his 
lips  knows  how  severe  the  pain  is  which  it  occasions,  and  will  appreciate 
the  torment  these  unfortunate  patients  must  have  gone  through.  The  pro- 
fession ought,  in  my  opinion,  to  have  visited  with  equal  1'eprobation  those 
who  perpetrated  such  shameful  experiments,  and  the  journals  which  lent 
them  the  sanction  of  their  columns.  I  beg  to  record  this  as  my  deliberate 
opinion.  To  give,  as  a  mere  experiment,  an  injection  producing  frightful 
pain  for  hours,  and  copious  discharge  of  blood,  is  in  my  judgment  a  most 
scandalous  act,  and  if  the  reader  will  kindly  hold  a  teaspoonful  of  one  of 
these  chloroform  injections  in  his  mouth  for  a  few  minutes  he  will,  I  think, 
be  of  my  opinion.  I  dare  say  these  abominable  tricks  now  and  then  ef- 
fected a  cure,  and  so  would,  perhaps,  an  injection  of  pure  sulphuric  acid, 
or  a  red-hot  wire,  with  the  additional  advantage  of  preventing  any  new  in- 
fection by  closing  up  the  urethra. 

Seeing  that  I  never  heard  an  opinion  on  the  subject  expressed  by 
any  one,  I  am  ignorant  whether  people  think  the  evil  of  this  dissonance  of 
opinion  is  past  cure,  or  is  so  slight  a  matter  as  not  to  require  anything  be- 
ing done  for  it.  To  me  it  seems  that  the  introduction  of  such  a  host  of 
new  remedies,  and  the  irreconcilable  difference  of  opinion  as  to  their  value, 
are  proof  enough  that  there  is  some  vital  defect  in  our  present  method  of 
trying  to  get  at  the  truth.  The  basis  on  which  our  principles  of  treatment 


104  ON    GONORRH(EA. 

rest  must  be,  indeed,  ready  at  any  instant  to  crumble  under  our  feet,  if 
all  the  teachings  of  authority  and  experience  are  liable  to  be  overturned, 
at  once,  in  favor  of  some  new  remedy  which  has  not  been  tested  in  more 
than  three  or  four  instances.  In  some  cases  in  the  literature  of  gonorrhrea, 
there  was  scarcely  even  this  ground  for  recommendation,  as  even  a  most 
cursory  examination  left  it  very  doubtful  if  the  substance  in  question  had 
exerted  any  influence  whatever  ;  e.g.,  the  evidence  about  honey  and  chloro- 
form was  of  this  class  ;  but  if  we  are  ever  to  attain  anything  like  accuracy 
in  medicine,  it  will  be  absolutely  necessary  to  have  a  better  system  of  re- 
cording cases,  the  best  that  I  can  suggest  being  what  I  first  suggested  quite 
thirty  years  ago,  a  school  of  experimental  medicine,  with  a  system  of  regis- 
tration for  correcting  errors  of  observation. 

The  disagreement  as  to  the  comparative  value  of  different  substances  for 
injection  has,  perhaps  naturally  enough,  extended  itself  to  the  strength  in 
which  they  are  to  be  employed,  especially  with  regard  to  the  nitrate  of 
silver,  the  recommendations  about  which  exhibit  such  a  variety  of  opinions, 
that  it  is  quite  impossible  to  understand  how  men  can  have  arrived  at  con- 
clusions so  diametrically  opposed.  Thus,  for  instance,  while  some  surgeons 
find  an  eighth,  a  quarter,  or  half  a  grain  of  nitrate  of  silver  to  the  ounce 
quite  strong  enough,  others  have  not  hesitated  to  use  solutions  of  a  scru- 
ple,1 or  even  half  a  drachm,2  in  the  same  amount  of  fluid  ;  and  it  has  been 
recommended  3  to  inject  a  solution  of  twenty  grains  to  the  ounce  not  merely 
once,  but  as  much  as  twice  or  even  thrice  in  the  twenty-four  hours.  Even 
this  heroic  treatment  was  not  active  enough  for  those  surgeons  who  advise 
that  the  solid  nitrate  should  be  employed. 

Cold  Water  Injections. — But  whatever  the  merits  or  demerits  of  the  nu- 
merous substances  and  systems  just  passed  in  review,  they  ought  now  to 
become  things  of  the  past,  the  progress  of  that  oblivion,  which  sooner  or 
later  conducts  most  of  them  to  one  common  tomb,  having  been  not  only 
accelerated  in  its  speed  but  extended  in  its  sphere  of  operation  by  a  dis- 
covery which  threatens  to  supersede  all  former  treatment  and  to  extin- 
guish all  interest  in  the  pathology  of  gonorrhoea  ;  for  who  would  waste  his 
time  in  studying  a  disease  which  is  almost  always  cured  at  a  single  sitting, 
and  never  lasts  more  than  a  few  days  ?  For  such  are  the  results  obtained 
by  Dr.  Morris,  of  Kentucky.4  He  introduces  a  catheter  with  a  large  olive- 
shaped  bulb,  the  latter  being  pierced  at  the  shoulders  and  closed  at  the 
point,  so  that  the  fluid  injected  flows  outward  and  backward,  not  into  the 
bladder.  The  catheter  being  introduced,  a  pump-syringe  is  connected 
with  it,  and  about  a  gallon  of  water  is  pumped  into  the  urethra  ;  after  this 
a  solution  of  sulphate  of  zinc  is  injected  by  means  of  a  "penis  syringe." 

1  Judd :  Op.  citat. ,  p.  6. 

8  Outlines  of  Military  Surgery.     By  Sir  George  Ballingall ;  p.  513.    1855. 

3  Berkeley  Hill :  Op.  citat. ,  p.  387. 

4  Southern  Medical  Record.    Quoted  in  British  Medical  Journal,  vol.  i ,  p.  194.   1882. 


TREATMENT.  105 

The  results  are  miraculous.  Out  of  twenty-five  cases  twenty-two  were 
cured  in  twenty-four  hours  ;  one  in  three  days,  and  another  in  seven  ;  while 
that  of  a  drinker,  who  continued  his  evil  courses  when  under  treatment, 
resisted  the  magical  power  of  the  remedies  for  fourteen  days. 

I  at  once  admit  that  I  never  heard  of  any  success  comparable  to  this  ; 
the  achievements  of  the  injections  which  cure  in  two  or  three  days  fade 
into  insignificance  before  such  results  ;  and  gonorrhoea  may  now  be  struck 
out  from  the  list  of  troublesome  disorders.  When  I  was  studying  this  dis- 
ease in  the  hospitals,  and  through  the  kindness  of  some  Mends  had  access 
to  a  practically  unlimited  number  of  out-patients,  I  never  once  saw  two 
successive  cases  cured  in  the  same  space  of  time  ;  and  never  saw  many 
cases  of  recent  infection  in  succession  without  meeting  with  one,  where  the 
urethra  was  so  inflamed  and  tender,  that  the  most  gentle  introduction  of 
the  silver  tubed  syringe  was  followed  by  great  pain  and  faintness,  neither 
of  which  seem  to  have  occurred  in  Dr.  Morris's  practice. 

The  method  was,  however,  tried  long  since,  Mr.  Windsor  tells  us,1  first 
apparently  by  M.  Reliquet,  who  as  far  back  as  1866  recommended  continu- 
ous irrigation  by  means  of  a  small  catheter,  kept  up  for  half  an  hour  to 
two  hours  ;  then  three  years  later  by  Dr.  Hewsou,  who  employed  a  double 
catheter;  in  1870  by  Mi-.  Durham,  and  again  in  1871  by  Mr.  Windsor," 
who  used  an  enema  ball  and  tube,  the  ivory  end  being  replaced  by  a  glass 
cylinder,  by  means  of  which  he  irrigated  the  first  three  or  four  inches  of 
the  urethra  with  cold  water  or  weak  solution  of  permanganate  of  potass, 
the  results  being  highly  satisfactory. 

Can  Injections  bring  on  Stricture  and  Orchitis  ? — To  this  pertinent  in- 
quiry the  most  unhesitating  denial  may  be  given,  provided  the  injections 
be  suitably  used.  Stricture  occurs  by  far  the  most  frequently  among  those 
who  have  been  treated  only  with  medicines,  or  with  medicines  and  injec- 
tions given  in  a  very  inefficient  manner,  and  is  so  rare  among  those  treated 
with  injections  properly  given,  that  in  the  course  of  many  years  I  have  never 
been  able  to  trace  a  single  case  to  this  source.  Mr.  Phillips  found  3  that, 
while  out  of  119  cases  117  had  been  preceded  by  urethra!  discharge,  astrin- 
gent injections  had  only  been  used  in  49  out  of  the  latter  set  of  cases. 

One  would  suppose  that  those  surgeons  who  object  to  their  use  on  this 
ground  would  have  adduced  some  facts  in  proof.  All  these  disorders  are 
so  common  that,  with  ordinary  industry,  any  writer  might  have  accumula- 
ted materials  enough  to  support  his  views.  But,  instead  of  doing  this,  they 
content  themselves  with  detailing  their  fears  of  what  ought  to  follow  ;  they 
never  appear  to  dream  of  relying  solely  upon  a  critical  analysis  of  what  has 
followed  the  use  of  such  means,  and  seem  entirely  to  have  lost  sight  of  the 
fact  that  the  evidence  of  some  of  our  best  observers,  of  men  like  Hunter, 

1  The  Liverpool  and  Manchester  Medical  and  Surgical  Reports,  p.  16.     1873. 
8  The  Manchester  Medical  and  Surgical  Reports,  p.  52.   1871. 
3  Op.  citat,  p.  226. 


106  ON    GONORRHCEA. 

Whateley,  Babington,  and  Ricord,  is  to  the  effect  that  contraction  of  the 
canal  does  not  result  from  their  employment. 

One  source  of  error  often  meets  us  here.  A  patient  contracts  a  gonor- 
rhoea and  uses  injections  for  it,  perhaps  also  takes  copaiba,  cubebs,  or  some- 
thing of  that  kind.  After  a  time  the  disease  gets  well.  By-and-by  the 
patient  contracts  another  infection,  and  this,  or  perhaps  a  third,  fourth,  or 
a  fifth  proves  obstinate  ;  the  surgeon  passes  down  a  bougie  and  finds  a 
stiicture.  Now  any  one  who  sees  many  of  these  cases  is  apt,  however  im- 
partial, to  think  that,  after  all,  there  may  be  some  truth  in  the  patient's 
opinion  that  the  narrowing  was  brought  about  by  the  injections.  And  this 
much  must  be  conceded.  In  very  irritable  systems  over  injecting  with 
quite  a  short  syringe  may  stimulate  distant  portions  of  the  urethra,  and 
possibly  lay  the  foundation  of  stricture,  even  though  not  a  drop  of  the  fluid 
ever  goes  near  the  site  where  this  afterward  springs  up.  Thus  I  was  con- 
sulted by  a  gentleman  who  had  been  under  the  care  of  a  well-known  sur- 
geon. The  surgeon  had  ordered  him  a  very  mild  injection  of  nitrate  of 
silver,  which  the  patient  had,  on  his  own  responsibility,  made  much  milder, 
reducing  it  to  about  one-eighth  of  a  grain  to  the  ounce.  This  he  threw  up 
several  times  daily,  and  then,  as  the  disease  did  not  get  better,  came  to  me. 
The  symptoms  did  not  seem  to  have  ever  been  severe,  and  there  was  clearly 
not  much  the  matter  with  him.  I  therefore  wanted  to  give  him  an  injec- 
tion of  a  grain  to  an  ounce,  and  to  use  it  myself,  so  as  to  try  if  I  could  end 
the  affair  at  once.  He  did  not  so  much  object  to  the  strength  of  the  solu- 
tion, as  to  the  idea  of  any  person  but  himself  inserting  an  instrument  into 
his  urethra,  and  I  had  to  content  myself  with  letting  him  use  the  injection, 
which  he  assured  me  he  could  do  perfectly  well.  I  found,  however,  that 
he  only  allowed  the  point  of  the  syringe  to  go  about  a  third  of  an  inch 
down  the  channel  of  the  urethra,  and  that  the  whole  of  the  fluid  streamed 
out  as  fast  as  it  was  thrown  in.  I  told  him  it  was  no  use  to  inject  in  that 
way,  but  he  was  convinced  that  the  method  had  so  far  worked  well,  and 
that  it  would  suffice  for  what  remained  of  the  disease,  so  he  continued  it. 

A  few  days  after  I  received  a  letter  from  him,  saying  he  was  suffering 
from  great  irritability  of  the  bladder  and  difficulty  in  making  water  ;  he 
therefore  asked  me  to  see  him  at  once.  After  he  had  taken  a  hot  bath  I 
passed  down  a  number  eight  gum  elastic  bougie.  About  four  and  a  half 
inches  down  the  instrument  encountered  a  very  tender  spot,  and  there 
was  some  difficulty  in  getting  farther.  It  was  here,  the  patient  said,  that 
he  found  the  obstacle  to  making  water.  After  twice  passing  the  bougie  I 
detached,  almost  certainly  from  this  spot,  a  clot  of  mucus  as  large  as  an 
extremely  small  nut.  It  was  ragged  in  outline,  grayish,  and  speckled  with 
a  darker  color,  much  as  we  see  in  patches  of  mucus  expelled  from  the 
trachea.  The  extrusion  of  this  mucus  was  succeeded  by  speedy  relief, 
and  passing  the  bougie  once  or  twice  more,  followed  by  a  couple  of  injec- 
tions with  a  long  syringe,  completed  the  cure. 


TREATMENT.  107 

Now  I  consider  I  am  warranted  in  assuming  that,  in  this  case,  the  in- 
jection aggravated  a  slight,  localized  inflammation,  already  existing  at  the 
part  of  the  urethra  from  which  the  mucus  came  away.  The  symptoms 
were  more  severe,  and  rose  more  rapidly  to  a  height  than  happens  in  such 
cases  when  no  injections  have  been  used.  But  I  think  it  is  pretty  clear 
that  what  mischief  was  done  by  the  injecting  must  be  put  down  to  the 
irritation  set  up  at  the  mouth  of  the  urethra,  and  not  to  the  action  of  the 
fluid,  as  none  of  it  could  have  reached  within  four  inches  of  the  tender 
part.  I  think  too,  after  weighing  ah1  the  circumstances  of  the  case,  that 
it  is  very  probable  stricture  might  have  sprung  up  at  the  spot  from  which 
the  mucus  came.  Some  amount  of  temporary  narrowing  had  indeed  al- 
ready begun. 

A  gentleman,  who  had  previously  suffered  severely  from  gonorrhoea, 
contracted  a  fresh  discharge  while  travelling  in  Belgium.  Desirous  to  cut 
it  short  as  quickly  as  he  could,  he  procured  some  "bru"  and  injected  it 
several  times  a  day  with  a  short  syringe.  At  the  end  of  a  few  days  he  be- 
gan to  suffer  from  extreme  irritability  of  the  bladder,  difficulty  in  making 
water,  bleeding  after  micturition,  dull  pain  over  the  loins,  languor  and 
loss  of  appetite.  In  this  state  he  returned  to  England,  and  almost  directly 
after  his  arrival  consulted  me.  I  found  him  very  low,  with  a  weak  quick 
pulse,  a  thickly  coated  tongue  and  almost  total  loss  of  appetite.  A  speci- 
men of  urine,  which  he  brought,  was  almost  chocolate  colored  from  hema- 
turia,  and  this  state  of  the  fluid  continued  for  nearly  a  fortnight.  A  num- 
ber six  bougie  passed  with  great  difficulty.  Two  or  three  years  previously 
I  had  several  times  passed  a  large  sized  instrument  with  ease. 

I  could  add  more  cases,  of  which  I  have  seen  several,  but  I  pass  on  to 
the  consideration  of  another  fact  of  which  I  have  also  seen  several  instances, 
which  is  that  over-injecting  with  a  short  syringe  will  sometimes  bring  on 
spasmodic  stricture,  great  irritability  of  the  posterior  part  of  the  urethra, 
and  a  good  deal  of  constitutional  disturbance,  even  when  there  is  not  and 
has  never  been  any  gonorrhoea.  Thus  a  gentleman  was  recommended  to 
inject  himself,  for  spermatorrhoea,  with  the  long  urethra!  syringe  ;  but  not 
feeling  at  all  assured  as  to  the  possible  results,  he  left  out  the  detached 
tube  and  injected  with  the  syringe  only.  He  had  only  done  this  "  once 
or  twice,"  according  to  his  account,  "  at  an  interval  of  a  day  or  two,"  when 
he  was  attacked  with  pain  about  the  prostate,  considerable  difficulty  in 
making  water,  great  disturbance  of  general  health,  loss  of  appetite,  head- 
ache, and  vomiting. 

Of  course  there  are  many  cases  to  which  such  an  explanation  as  that  given 
of  the  first  case  would  not  apply  ;  those  for  instance  where  the  nitrate  solu- 
tion is  applied  all  over  the  urethra.  Here  I  believe  the  explanation  of  the 
problem  is  to  be  found  in  the  inability  of  nitrate  of  silver  to  cure  gonorrhoea 
without  the  aid  of  other  means.  My  conclusion  would  be,  that  the  con- 
traction is  not  caused  by  the  employment  of  the  nitrate,  but  that  it  invari- 


108  ON    GONORRH<EA. 

ably  ensues  in  a  certain  percentage  of  cases  when  treatment  fails  to  arrest  the 
discharge. 

In  five  cases  I  have  traced  stricture  to  the  abuse  of  chloride  of  zinc  in- 
jections, and  twice  to  over-strong  injections  of  the  perchloride  of  mercury. 
My  reasons  for  ascribing  the  contraction  here  to  the  injection  are,  that  in 
every  instance  the  fluid  used  was  either  so  strong,  or  thrown  in  so  often,  that 
severe  pain  and  difficulty  in  making  water  were  set  up  at  the  time  ;  and  that, 
also,  in  every  instance,  on  the  subsidence  of  these  symptoms,  a  bougie  was 
passed  and  narrowing  was  found  to  have  begun. 

If  injections  bring  on  orchitis,  how  is  it  that  they  scarcely  ever  produce 
this  effect  when  given  within  the  first  fortnight  from  the  breaking  out  of  the 
disease — the  very  time  when  they  induce  the  most  pain  ?  M.  Diday  and 
M.  Bicord  have  never  seen  this  complication  before  the  fifteenth  day,1  and 
I  have  not  observed  it  in  my  practice  so  early  as  this  in  a  single  instance, 
though  M.  Le  Fort  noticed  it 2  twenty-four  times  during  the  first  week  out 
of  six  hundred  and  forty -five  cases.  If  the  strength  of  injections  is  the 
object  to  be  dreaded,  how  does  it  happen  that,  in  the  cases  mentioned  in 
Table  V.,  where  eighteen  persons  were  treated  with  solution  of  nitrate 
of  silver,  ten  grains  to  an  ounce,  no  symptoms  of  orchitis  were  induced 
in  any  instance — a  result  I  have  since  repeatedly  verified,  not  indeed 
altogether  from  my  own  practice,  for  I  have  always  dissuaded  patients  from 
such  a  step,  but  from  observing  the  effects  in  the  hands  of  others  ? 

I  must  now,  upon  the  lowest  calculation,  have  given  with  my  own  hands 
injections  of  nitrate  of  silver  several  thousands  of  times  in  gleet  and  sperma- 
torrhoea, and  as  I  have  not  yet  seen  orchitis  or  stricture  arise  from  doing 
so,  I  am  inclined  to  think  that  such  a  result  is  not  to  be  expected  when  the 
operation  is  properly  performed. 

When  a  patient  has  neglected  a  gonorrhoea  for  some  time,  say  three  or 
four  weeks,  or  has  been  for  a  time  trusting  to  medicines  only,  and  in 
consequence  of  not  deriving  from  them  the  benefit  he  expected,  takes  to 
injections,  it  will  sometimes  happen,  that  so  soon  as  these  are  begun  with 
orchitis  comes  on  ;  and  I  need  scarcely  say,  that  should  this  complication 
occur  at  any  period  when  these  remedies  are  being  used,  it  is  at  once 
ascribed  to  their  employment.  I  am  rather  disposed  to  think,  that  in  some 
of  those  cases  the  use  of  the  injection  does  hasten  the  appearance  of  the 
swelling,  but  that  it  cannot  be  considered  as  the  sole,  or  even  the  chief, 
cause.  Even  as  an  exciting  cause  its  agency  must,  I  apprehend,  be  limited 
to  this,  that  it  calls  forth  what  would  have  happened  spontaneously  at  a  later 
date.  I  have  not  found  orchitis  more  prevalent  under  such  circumstances 
than  where  medicines  alone  were  trusted  to  ;  and  my.  experience  is,  that  a 
certain  percentage  of  this  complication  will  happen  under  any  system  of 
treatment  which  does  not  cut  short  the  gonorrhoea  within  a  few  days. 

1  Exposition  critique,  p.  484. 

'Medical  Times  and  Gazette,  vol.  ii.,  p.  52.  1869. 


TREATMENT.  109 

In  contrast  to  the  authors  who  declaim  so  vaguely,  Mr.  Johnson  gives 
us  '  something  tangible.  Out  of  the  fifty-nine  cases  of  orchitis  which  he 
quotes,  sixteen  were  known  to  have  used  injections,  and  nine  had  taken 
copaiba.  Out  of  thirteen  cases  of  swelled  testicle  admitted  into  Guy's  Hos- 
pital twelve  had  followed  gonorrhoea.  Of  these  twelve  patients  only  one 
had  used  injections.  Four  of  them  had  taken  copaiba,  but  only  one  of 
them  had  succeeded  in  checking  the  gonorrhoea  with  it.3  The  remaining 
seven  had  neither  used  injections  nor  taken  copaiba.  Facts  then,  here,  are 
against  the  supposition  that  these  remedies  possess  any  such  power. 

I  presume  it  is  unnecessary  to  discuss  such  questions  as  the  power 
of  injections  to  throw  any  infection  into  the  system,  or  produce  a  metas- 
tasis of  the  disease,3  or  do  harm  by  checking  the  purulent  running.  Such 
doctrines  might  do  very  well  for  a  country  nurse,  or  the  feeble-minded 
class  of  persons  who  encourage  homoeopathy,  or  join  anti- vaccination 
leagues  ;  but  I  need  scarcely  say  that  the  opinions  of  such  people,  when 
utterly  unsupported  by  truth,  do  not  require  discussion.  Farther,  I  am  not 
aware  that  the  questions  themselves  have  ever  been  supported  by  any  rea- 
sons. Therefore  as  I  shall  have,  later  on,  to  examine  the  question  of  metas- 
tasis more  fully,  I  pass  by  this  part  of  the  subject,  simply  remarking  that 
what  is  really  wanted,  is  not  the  putting  an  end  to  frivolous  objections,  but 
to  the  gonorrhoea,  and  that  without  giving  pain,  and  in  the  shortest  possible 
space  of  time.  Long  ago  Hunter  pointed  out 4  that  injections  could  not 
possibly  drive  the  disease  into  the  system,  because  the  poison  resides  in  the 
secreted  matter. 

A  very  similar  kind  of  dread  prevails  about  checking  gonorrhoea  at  all 
in  the  acute  stage.  Mr.  Johnson  says  that  at  this  period  of  the  disease 
"the  more  discharge  the  better."  But  it  is  certain  that  the  more  dis- 
charge the  more  extensively  and  severely  is  the  urethra  affected,  and, 
cceteris  paribus,  the  longer  does  it  take  to  cure.  Besides,  it  is  utterly  im- 
possible to  suppress  a  discharge  except  by  means  which  make  the  mem- 
brane secreting  it  healthier,  and  it  is  difficult  to  understand  how  that  can 
be  injurious  to  the  patient.  Very  strong  remedies  used  for  the  purpose  of 
trying  to  cure  gonorrhoea  may  do  mischief  ;  but  it  is  because  they  set  up 
pain  and  irritation,  not  because  they  stop  the  discharge. 

We  might,  I  think,  deal  in  the  same  way  with  the  question  of  not  giv- 
ing injections  till  the  acute  stage  has  passed  off.  Mr.  Berkeley  Hill,  one  of 
the  most  recent  writers  on  this  subject  says  5  that  "  recourse  to  them 
should  never  be  had  until  the  acute  inflammation  has  completely  sub- 
sided," and  I  suppose  it  may  be  safely  said  that  Mr.  Hill  is  here  the  expo- 
nent of  a  wide-spread  belief.  But,  even  with  authorities  against  me,  I 
must  maintain  the  opinion  to  be  groundless.  I  have  for  years  employed 

1  Op.  citat.,  p.  197.          2  Guy's  Hospital  Reports,  3d  Series,  vol.  viii.,  p.  467. 

3  Howard  :  Op.  citat.,  vol.  iii.,  p.  123. 

4 Op.  citat.,  p.  77.  *  Op.  citat.,  p.  402. 


110  ON    GONORRHOEA. 

injections  so  soon  as  ever  I  could  obtain  the  patient's  consent  to  let  me  use 
them,  and  have  never  in  a  single  instance  had  to  regret  doing  so. 

Nitrate  of  Silver. — Of  all  the  substances  ever  yet  employed  for  injec- 
tions this  is,  to  my  thinking,  the  best.  I  have  seen  a  great  number  of  in- 
jections tried,  and  have  one  time  or  other  tried  a  good  many  myself,  but  I 
have  never  observed  any  exercise  such  a  marked  control  over  gonorrhoea 
as  a  solution  of  nitrate  of  silver,  properly  given,  and  of  the  proper 
strength.  Yet  it  is  used  by  comparatively  few  practitioners,  and  it  is  no 
uncommon  thing  to  hear  surgeons  say  that  they  have  given  it  up  in  conse- 
quence of  failing  so  often  with  it,  or  from  its  bringing  on  stricture.  The 
latter  objection  is,  I  think,  already  got  over.  The  former  merits  decided 
attention. 

I  am  not  sure  about  the  matter,  but  I  believe  the  merit  of  first  using 
this  powerful  remedy  is  due  to  an  East-India  surgeon,1  who,  being  de- 
tained for  some  time  "  on-  the  island  Madagascar,"  about  the  year  1737, 
practised  on  the  natives  !  Certainly 

"  Illi  robur  et  aes  triplex 
Circa  pectus  erat. " 

He  used  to  dissolve  three  grains  in  half  a  pound  of  soft  water,  and  thicken 
it  a  little  with  powdered  coral.  But  it  was  too  bold  a  flight  for  the  physi- 
cians of  that  day,  and  even  for  those  of  a  later  date,  so  that  for  something 
like  a  century  afterward  this  valuable  remedy  remained  almost  totally 
neglected. 

When  aided  by  medicines  and  employed  at  the  very  outbreak  of  the 
disease,  and  particularly  in  mild  cases,  it  will  often  cure  gonorrhoea  with 
great  rapidity.  This  fact  I  think  no  one  will  deny.  In  some  instances  its 
action  is  so  sudden  that  on  the  very  next  day  only  a  slight  gleet  remains, 
which  soon  vanishes  under  the  influence  of  any  mild  astringent.  Even  if 
it  fail,  it  generally  so  alters  the  action  of  the  parts  that  very  simple  means 
will  remove  the  dregs  of  the  disease  ;  and,  in  point  of  fact,  much  greater 
progress  toward  a  speedy  and  lasting  cure  is  often  effected  by  one  in- 
jection, than  by  the  most  heroic  employment  of  antiphlogistic  medicines, 
rest,  and  low  diet.  But  it  does  not  always,  or  indeed  often  succeed  when 
used  alone,  and  then  in  bad  cases  the  disease  will  go  on,  and  stricture  will 
set  in,  or  some  other  complication  will  ensue,  and  the  surgeon  is  blamed 
for  using  injections,  "  driving  the  disease  in,"  and  ruining  the  patient's 
constitution. 

That  its  power,  as  a  purely  curative  agent,  when  employed  without 
the  aid  of  other  means  is,  in  the  general  run  of  cases,  very  limited,  I  am 
quite  satisfied.  As  an  instance  out  of  many  others,  I  selected  eighteen  pa- 
tients who  were  anxious  to  be  cured  at  once,  at  all  risks  ;  they  were  in- 

1  Howard  :  Op.  citat.,  vol.  iii.,  p.  136. 


TREATMENT. 


Ill 


jected  with  a  solution  of  nitrate  of  silver,  ten  grains  to  an  ounce  ;  a  dose 
of  calomel  and  opium,  with  a  purgative  draught  was  ordered,  and  the  fol- 
lowing results  were  obtained  : 

TABLE  V. 
Coses  treated  with  Strong  Injections  of  Nitrate  of  Silver. 


Names. 

Number  of 
days  the 
disease  had 
lasted. 

Symptoms  and  result. 

J.  B. 

60 

Pain,  bloody  urine,  but  improvement  ;  still  some 

discharge. 

J.  N. 

90 

Pain  and  scalding  lessened.     Improvement  ;  still 

some  discharge. 

S.  B. 

270 

Much  pain  and  scalding  ;  little  improvement. 

H.  H. 

29 

Some  pain  ;  great  improvement  ;  discharge  les- 

sened. 

J.  W. 

17 

Great  pain  ;  discharge  much  lessened. 

E.  C. 

35 

So   much  pain   caused  that  he  refuses  to  have 

another  injection.     Discharge  lessened. 

J.  B. 

5 

Great  pain  for  four  hours  after  ;  no  discharge  to 

be  seen  ;  cure. 

G. 

14 

So  much  pain  that  he  will  not  be  injected  again. 

The  discharge  is  lessened. 

E.  G. 

14 

Great  pain  ;  the  discharge  went  away  and  then 

returned,  but  it  is  lessened. 

B. 

10 

So  much  pain  that  he  has  no  desire  to  have  it  re- 

peated ;  speedy  cure. 

W.  N. 

18 

Great  pain  ;  the  discharge  is  gone. 

E.  E. 

23 

Discharge  almost  gone  ;  irritability  of  the  urethra 

greater  ;  rapid  cure. 

H.  H. 

60 

Not  much  pain  ;  the  discharge  lessened. 

H.  C. 

130 

Pain  for  three  hours  ;    the   scalding  increased  ; 

discharge  lessened. 

R  T. 

21 

The  pain  trifling  ;  pain  and  uneasiness  in  the  penis 

and  scrotum  relieved  ;   the  discharge   almost 

immediately  lessened. 

J.  R 

5 

Great  pain  ;  the  discharge  was  stopped,  and  then 

slowly  returned. 

J.  T. 

2 

Lost  sight  of. 

W.  H. 

42 

Lost  sight  of. 

Here,  then,  we  see  that  out  of  the  eighteen  two  were  immediately  cured, 
and  in  nine  others  there  was  a  considerable  improvement ;  some  of  them, 
indeed,  were  quickly  freed  from  their  malady,  though  they  had  long  suffered 
under  it.  Of  the  remaining  seven,  two  disappeared  without  giving  notice, 
and  the  residue  were  not  cured  for  a  long  time. 


112  ON    GONORRHOEA. 

Subsequent  experience  has  only  tended  to  corroborate  the  conclusions 
then  arrived  at.  Over  and  over  again  patients  have  applied  to  me  with 
the  request  that  I  would  cure  them  with  a  strong  injection  and  without 
medicines,  but  the  result  has  generally  been  that  I  was  obliged  to  resort 
to  the  use  of  the  latter,  and  that  the  injection  failed,  Many  facts  corrob- 
orating this  statement  have  been  communicated  to  me  ;  from  among  them 
I  select  the  following.  A  physician  told  me  that  he  had,  in  his  own  case, 
when  a  student,  attempted  to  cut  short  a  gonorrhoaa  by  means  of  a  strong 
injection  of  nitrate  of  silver.  He  did  not  know  the  exact  strength  of  the 
solution,  but  it  was  at  least  fifteen  or  twenty  grains  to  the  ounce  and 
might  have  been  more.  Pain  of  the  most  violent  kind  was  at  once  set  up. 
Two  or  three  days  after  he  noticed  a  dark  substance,  like  a  slough,  pro- 
truding from  the  urethra.  Taking  hold  of  this  he  gradually  drew  it  out. 
So  great  was  its  length  that  it  seemed  to  be  almost  endless,  and  he  as- 
sured me  that  it  proved  to  be  five  inches  long  (!)  yet  the  gonorrhoea  went 
on  utterly  uninfluenced  by  the  violent  action  which  had  been  set  up  in  the 
urethra.1 

The  late  Mr.  Acton's  experience  was  certainly  very  different.  He 
generally  found  two  strong  injections  of  nitrate  of  silver  quite  sufficient. 
He  seldom  had  recourse  to  a  third,  and  his  patient  was  "  quit  of  a  trouble- 
some complaint  in  a  very  few  days." 2  M.  Diday,  who  employs  strong  in- 
jections, speaks 3  quite  confidently  of  curing  the  disease  at  a  single  sitting 
with  an  injection  ("d'un  seul  coup  de  piston"  .  -.  .  "en  une  se- 
ance ").  His  one  injection,  however,  really  means  two,  or  what  he  calls  * 
a  "  seance  d'injections,"  one  being  required  to  clear  the  way  for  the  other. 
The  curative  injection  is  a  solution  of  the  nitrate,  not  quite  ten  grains  to 
an  ounce  (three  decigrammes  of  the  nitrate  to  eighteen  grammes)  of  dis- 
tilled water.  He  injects  about  a  drachm  of  this,  keeps  it  for  about  a 
minute  in  the  urethra,  and  all  is  finished.  Of  course  this  applies  to  cases 
seen  at  an  early  stage  ;  but  still,  as  I  understand  M.  Diday,  when  the  dis- 
ease is  unmistakably  there.  His  later  experience,  however,  seems  to  be 
rather  different. 

According  to  what  seems  a  very  trustworthy  report 6  of  twenty  cases 
treated  in  Edinburgh  Castle  by  Messrs.  Johnson  and  Bartlett  with  injec- 
tions of  nitrate  of  silver,  twenty  grains  to  an  ounce,  the  results  were  as 
follows  :  One  case  was  discharged  cured  in  three  days,  one  in  five  days, 
one  in  six,  two  in  ten,  four  in  fifteen,  four  in  seventeen,  four  in  twenty, 
one  in  twenty-five,  one  in  twenty-eight,  and  one  in  forty-two,  the  average 


1  Zeissl  relates  a  case  far  surpassing  this.     He  saw  the  whole  mucous  membrane  of 
the  urethra  (!)  cast  off,  under  violent  bleeding,  like  a  sheath  (wie  ein  Schlauch).  from 
a  young  physician  having  imprudently  thrown  in  a  strong  solution  of  caustic.     Wiener 
medizinische  Wochenschrift,  S.  100.     1879. 

2  Op.  citat.,  p.  90.  3  Exposition  critique,  p.  88.  40p.  citat.,  p.  91. 
5  Edinburgh  Medical  and  Surgical  Journal,  p.  263.     1818. 


TREATMENT.  113 

time  for  a  cure  being  seventeen  days  and  a  tenth.  These  statistics  do  not 
differ  so  widely  from  those  which  I  obtained,  though  they  are  in  utter  con- 
flict with  what  M.  Diday  and  Mr.  Acton  tell  us. 

Chloride  of  zinc,  first  proposed,  I  believe,  as  an  injection  by  M.  Gau- 
driofc,1  was  at  one  time  strongly  recommended  by  the  late  Mr.  Lloyd,  of 
St.  Bartholomew's  Hospital.  It  is  not  often  that  there  happens  such  a 
success  with  any  novelty  in  the  therapeutics  of  gonorrhoea  as  occurred  in 
this  instance.  According,  however,  to  a  pretty  general  rule,  the  perform- 
ance, when  the  remedy  came  to  be  fairly  tested,  proved  to  be  so  much  be- 
low the  expectations  raised,  that  the  choride  fell  into  very  unmerited  dis- 
repute. 

During  the  winter  preceding  the  appearance  of  Mr.  Lloyd's  lecture 
recommending  the  chloride,  I  had  been  engaged  for  several  hours  nearly 
every  day  in  examining  the  value  of  certain  substances  as  injections.  Among 
these  was  the  salt  in  question.  As,  however,  my  observations  ran  quite 
counter  to  those  of  Mr.  Lloyd,  I  never  had  the  least  idea  of  claiming  any 
priority  ;  in  fact,  I  could  not  claim  it,  because  I  never  discovered  such  valu- 
able properties  in  this  salt  as  he  did. 

The  patients  on  whom  the  chloride  was  used  were  seen  daily,  Sunday 
excepted.  They  were  injected  at  each  visit  with  a  solution  varying  in 
strength  from  one  to  ten  grains  in  an  ounce  of  distilled  water,  and  every 
effort  was  made  so  to  regulate  the  strength  of  the  injection  as  to  avoid 
giving  anything  like  severe  pain,  while  a  decided,  though  slight  sensation, 
lasting  from  a  quarter  to  half  an  hour,  was  aimed  at.  The  patients  were  in- 
structed in  the  use  of  the  syringe,  and  furnished  with  a  weak  solution  of 
the  same  salt  to  use  at  home.  The  disease  was  at  the  same  time  combated 
with  aperients,  salines,  and  in  some  cases  copaiba  and  turpentine,  and  the 
patients  were  diligently  questioned  as  to  every  indulgence  in  diet,  drink, 
and  sexual  intercourse. 

Notwithstanding  all  this  care,  more  pain  was  caused  than  with  nitrate 
of  silver  or  sulphate  of  zinc,  while  the  disease  did  not  disappear  more 
quickly.  In  some  cases  it  proved  ineffectual,  and  had  to  be  superseded  by 
nitrate  of  silver  or  blistering  ;  in  two  stricture  sprang  up,  and  some  patients 
left  dissatisfied,  so  that  I  was  induced  to  give  it  up  ;  in  one  or  two  instances 
only  was  it  of  benefit  when  the  nitrate  of  silver  failed.  I  tried  weaker  so- 
lutions, commencing  with  a  quarter  of  a  grain  to  an  ounce,  but  after  two 
years'  careful  examination  I  was  compeUed  to  return  to  the  conclusions 
previously  arrived  at,  namely,  that,  cceteris  paribus,  the  chloride  is  equal 
but  not  superior  to  the  acetate  and  sulphate  ;  and  I  may  mention  that  I 
have  seen  so  many  cases  in  which  stricture  followed,  either  from  the  chlo- 
ride possessing  no  proper  control  over  the  disease,  or  from  its  really  ad- 
ding to  the  existing  irritation,  that  I  think  its  action  ought  to  be  carefully 
watched. 

1  Journal  des  Connaissances  medicales,  Septembre,  1840. 
8 


114  ON    GONORRHOEA. 

When  used  of  the  proper  strength — that  is,  so  strong  as  only  to  pro- 
duce transient  pain,  no  one  of  the  salts  of  zinc  appears  to  me  to  possess 
greater  curative  power  than  another,  but  in  respect  to  the  amount  of  suffer- 
ing they  may  entail,  when  used  too  strong,  they  differ  more  widely  ;  for 
while  the  sulphate  produces  a  sharp  fleeting  pain,  seldom  difficult  to  en- 
dure, that  from  the  use  of  the  acetate  is  more  severe,  and  I  have  seen  abso- 
lute torture  arise  from  the  employment  of  the  chloride,  even  in  a  solution 
of  moderate  strength.  One  patient  said  that,  "if  it  were  not  considered  a 
liberty,  he  would  beg  to  draw  my  attention  to  the  close  resemblance 
between  the  sensation  induced,  and  that  which  he  should  fancy  would 
be  brought  on  by  passing  a  red-hot  knitting-needle  along  the  ure- 
thra ! " 

Hence  I  am  inclined,  in  cases  where  there  is  much  pain,  to  prefer  the 
sulphate  ;  if  very  little  pain  be  present,  the  chloride  may  be  prescribed. 
As  to  the  sulphate  of  alum,  the  sulphate  of  copper,  and  one  or  two  other 
substances  of  the  kind,  on  which  I  foolishly  wasted  my  time  and  that  of  the 
patients,  I  am  disposed  to  consider  them  as  of  very  inferior  value.  A  tabu- 
lar view  of  the  results  of  injection  of  several  substances  is  given  from  Mr. 
Judd's  excellent  treatise  at  page  118,  and  the  reader  can  compare  it,  if  he 
likes,  with  what  I  have  stated. 

I  have  been  so  often  questioned,  both  by  surgeons  and  patients,  as  to 
how  injections  act,  that  I  seize  this  opportunity  of  publicly  avowing  my 
total  ignorance  of  the  subject.  My  readers  will  be  good  enough  to  bear  in 
mind  that  no  instrument  as  yet  contrived,  even  one  so  valuable  and  elabor- 
ate as  the  endoscope,  enables  us  to  examine  more  than  a  portion  of  the  ure- 
thra, and  that  only  for  a  very  short  space  of  time.  Next,  I  suppose,  it  will  be 
admitted,  that  to  observe  with  precision  what  is  being  done  in  such  a  mat- 
ter, the  surface  operated  on  must  be  seen.  In  that  case,  a  man  must  be  able 
to  look  bodily  down  the  urethra  for  hours,  or  right  through  its  walls.  Far- 
ther, it  would  be  necessary  for  the  eye  of  the  observer  to  possess  a  special 
magnifying  power  of  from  225  to  450  diameters  ;  otherwise  all  that  could 
be  seen  would  probably  be  a  certain  amount  of  punctate  redness  of  the 
urethra,  the  formation  of  a  filmy  coat  of  white  deposit  (supposing  the  ni- 
trate were  used),  followed  by  increased  redness  and  then  a  somewhat  paler 
hue  than  before.  When,  therefore,  I  find  a  writer  attempting  to  explain 
the  action  of  these  fluids  by  the  hypothesis  that,  "  by  arresting  the  dis- 
charge they  relieve  the  urethra  from  the  stimulus  of  the  virus,"  '  or  that 
they  "  close  up  the  orifice  of  the  ducts  "  (what  ducts?),  or  that  they  "dry 
up  the  discharge  without  curing  the  inflammation,"  when  the  discharge 
arises  solely  from  the  inflammation,  I  really  cannot  help  thinking  that  such 
statements  do  not  tend  to  raise  the  character  of  medicine  among  sensible 
men.  If  I  were  pressed  to  give  an  opinion  on  the  matter,  I  should  feel 
tempted  to  say,  that  I  do  not  believe  any  person  knoivs  how  injections  act, 
1  Babington  :  Works  of  John  Hunter,  vol.  ii.,  p.  208. 


TREATMENT. 


115 


and  that,  in  the  present  state  of  medicine,  any  explanation  must  simply 
mean  theory  founded  on  personal  conviction. 

I  think  it  just  possible  that  the  modus  operandi  is  as  follows :  The  se- 
cretion of  pus  is  equivalent  to  exalted  action  in  the  mucous  membrane  of 
the  urethra,  which  means  that  there  is  an  accumulation  of  vital  force  at  the 
part,  for  there  could  be  no  secretion  without  motion,  and  without  force 
being  applied  there  could  be  no  motion.  Now  it  seems  pretty  clear  that, 
while  a  part  will  go  on  with  a  certain  amount  of  morbid  action  for  a  time, 
the  application  of  certain  agents  to  this  part  being  superadded,  so  as  to 
produce  a  sudden  increase  of  this  morbid  action,  a  rebound  takes  place  ; 
and,  as  the  action  of  the  agent  subsides,  the  part  is  found  less  capable  of 
continuing  the  morbid  action  for  the  time,  or,  in  other  words,  there  is  less 
accumulation  of  vital  power  in  it.  I  have  repeatedly  traced  this  form  of 
action,  for  instance,  in  the  application  of  a  blister  or  galvanism  to  a  slug- 
gish ulcer ;  the  influence  of  erysipelas  on  the  same  disease,  and  on  lupus ; 
the  operation  of  a  blister  in  gleet,  and  in  some  obstinate  forms  of  tinea  ; 
where  the  morbid  action  is  first  increased  and  subsequently  diminished  by 
one  and  the  same  agent ;  and  in  a  series  of  lectures,  published  under  the 
title  of  "  The  Laws  of  Life,"  I  have  gone  pretty  fully  into  the  question. 
But  any  lengthened  digressions  on  such  a  subject  would  be  quite  out  of 
place  in  a  work  like  this,  and  I  therefore  gladly  revert  to  the  more  practi- 
cal part  of  the  subject,  and  give  in  a  tabulated  form  the  results  of  my  trials 
with  the  chloride.  • 


TABLE  VI. 
Cases  treated  with  Injections  of  Chloride  of  Zinc. 


Name. 

Days 
previously 

ill. 

Character 
of  the  disease. 

Strength  of 
injection. 

Treatment. 

Results. 

J.  A. 

42 

Mild. 

gr.  v.  to  §  j  . 

Pil.    t  e  r  e  b.  c. 

At  the  end  of  15  days 

strych. 

little  improvement. 

O.  s: 

3 

Thick  pus, 

gr.  ijss. 

Salines. 

Swelled  testicle.  In  21 

severe. 

. 

days  discharge  gone. 

A. 

Not 

Severe. 

Ditto. 

Acet.  pot. 

No    improvement    on 

marked. 

25th  day.      Treated 

then  with  purgatives 

and  nitrates.     Cured 

in  about  52  days  af- 

ter. 

0.  L. 

1 

Ditto. 

gr.  ijss.  to  iv. 

Nit.    pot.    c.    p. 

No    improvement    at 

ipec.    co.  ;   sa- 

the end  of  27  days. 

lines  and   ape- 

Left. 

rients. 

c.  c. 

21 

Ordinary. 

gr.  jss.adijss. 

Pulv.     sal  in.  ;  ,  The  plumb,  acet.  was 

mist,  acid  benz. 

used  for  12  days,  and 

then   the    chl.    zinc, 

which   almost  cured 

him  in  2  days.    Left 

not  quite  well. 

116 


ON   GONORRH(EA. 


Name. 

Days 
previously 
111. 

Character 
of  the  disease. 

Strength  of 
Injection. 

Treatment. 

Results. 

J.  S. 

11 

Severe. 

gr.  ijss.  and 

Pot.  nit.  c.  pulv. 

S  e  v  e  r  e    pain  ;    dis- 

ij. 

ant.  ;  pulv.  sa- 

charge    disappeared 

lin.,  etc. 

in  2   days,    but  re- 

|     turned.    On  the  31st 

day  still  a  little  gleet. 

C.  L. 

12 

Ordinary. 

gr.  iij.  and 

Pot.  nit.  c.  pulv. 

Gave    him    so    much 

ij- 

ipecac,  c. 

pain  he  would  allow 

it  no  longer. 

A.S. 

21 

Ditto,   first 

gr.  ijss.  ad  x. 

Sulph.  magnes.,  ;  In  8  days  there   was 

clap. 

pulv.    sod.    c. 

only  a  little  moisture, 

opio  pulv.  sa- 

and this  remained  10 

lin. 

days  after,  when  he 

left  me.    Gr.  x.  gave 

only  slighj  pain. 

C.  G. 

4 

Severe, 

gr-  J- 

Pulv.  salin.,  pot. 

In   8    days   discharge 

second  clap. 

nit.     c.     pulv. 

had  diminished,  but 

ipec.  c. 

swelled  testicle  came 

on.  and  he  left  me. 

D.  M. 

3  to  4 

Ordinary. 

gr.  vijss.  to 

Pulv.  salin. 

Discharge  disappeared 

months. 

ij- 

in  11  days. 

J.  M. 

6 

Ditto. 

gr.  ij.  ad  iv. 

Ditto,  pot.  nit., 

At  end  of  37  days  dis- 

and then 

mist,  salin. 

charge  still  thick,  pu- 

to vijss. 

rulent,  and  greenish. 

T.  R. 

4  or  5 

Ditto. 

gr.  j.  to  iij. 

Salines,     pulv. 

Caustic    pastilles  had 

salin.,    mist. 

to  be  resorted  to  on 

cop.  c.  tereb. 

the   15th   day;    the 

cure   was  somewhat 

prolonged  by  his  ab- 

• 

sence   for   a  day  or 

two.  Cure  in  62  days. 

R.L. 

Not 

Very  mild. 

gr-  ij- 

Mist,  acid  benz.     Left  the  next  day. 

known. 

S.  L. 

Ditto. 

Mild. 

gr.  iij.  to 

Ditto,    pulv.  sa-    Discharge  disappeared 

vijss. 

lin.,   bark  and       in   6    days.      But   a 

acid.                         slight  gleet   came 

back  and  lasted  30 

days. 

W.H. 

21 

Very  severe. 

.... 

Ditto,  ditto,  pot. 

On  the  40th  day   the 

nit. 

discharge    was    still 

bad.     He  then  left. 

G.  C. 

10 

Ordinary. 

gr.  j.  to  v.      Pulv.  salin. 

Disappeared  in  8  days. 

T.  J. 

49 

Very  mild. 

gr.  j.          Sod.  phos.,  sod. 

The   discharge    was 

sulph.  ,     and 

nearly   gone  by  the 

mist,  acid  benz. 

9th  day,  when  he  left. 

R.  A. 

Not 

Severe. 

gr.  jss.  to  v.     Pulv.    salin., 

On  the  20th   day  he 

marked. 

mist.     pot. 

left  as  bad  as  ever. 

c  h  1  o  r.  ,   tinc- 

ture   of  steel, 

pot.  acet. 

C.  H. 

A  few 

Ditto. 

gr.  j.  toij. 

M.    acid    benz., 

38th    day    no  better. 

days. 

pot.    nit.    c. 

This   case    was    fol- 

pulv.   ant. 

lowed  by  stricture. 

pulv.  salin. 

W.  T. 

8 

Ditto. 

gr.  j.  to  v. 

Pulv.  salin,  etc. 

Stricture   detected  on 

months. 

the  75th  day. 

R.  S. 

3 

Ordinary. 

gr.  j. 

Pulv.  salin.,  bit- 

The discharge  gone  in 

months. 

ters  and  acid. 

10  days  :  a  little  gleet 

from  time  to  time. 

T.  S. 

Not 

Ditto. 

gr.  v. 

Mist.  pot.  ac.  c. 

Left  next  day. 

marked. 

rheo. 

TKEATMENT. 


117 


In  conclusion,  I  may  say  that  I  think  very  favorably  of  both  the  chlo- 
ride and  sulphate  of  zinc,  employed  as  adjuncts  to  other  treatment  The 
mode  of  thus  using  them  will  be  examined  farther  on. 

The  reader  can  now  compare  the  average  results  of  treatment,  as  put 
down  in  those  tables,  with  those  in  a  series  of  cases  extracted  from 
Ricord's  "Traite  Pratique,"  and  from  Mr.  Judd's  work.1  The  first  column 
of  the  three  in  Table  "VTL,  compiled  from  cases  in  the  "  Traits  Pratique,"  A, 
marks  the  number  of  days  between  the  date  of  infection  and  the  entry  of 
the  patient  into  the  hospital.  The  second  column,  B,  means  the  number 
of  days  the  patient  stayed  in  the  hospital  under  treatment.  The  third 
column,  C,  contains  the  principal  remedies  used. 


TABLE  VH 
Cases  treated  by  Eicord. 


A. 

B. 

C. 

A. 

B. 

C. 



20    Injections  and  cubebs. 

15 

25 

Inject,  arg.  nit 

30 

27     Copaiba. 

30 

20 

Inject,  arg.  nit.  copaiba. 

15 

20 

Copaiba. 

6° 

20 

Ditto. 

Old 

10 

Injections  of  alum. 

21 

20 

Inject  zinc  sulph. 

Gleet 

33 

Inject,  argent,  nit. 

8 

20 

Cubebs  and  inject,  arg. 

8 

20 

Inject,  argent,  nit. 

nit 

— 

32 

Ditto  and  copaiba. 

— 

35 

Inject. 

30 

35 

Inject  zinc.  sal.  and  cu- 

63 

30 

Cauteriz.  and  cubebs. 

bebs. 

60 

34 

Inj.   plum.  diac.  and  co- 

8 

31 

Cubebs,  steel. 

paiba. 

10 

41 

Cubebs  and  injections. 

11 

17 

Copaiba  and  cauteriz. 

4 

21 

Inject,  arg.  nit.  and  co- 

5 

28 

Argent,    nit.    and    co- 

paiba. 

paiba. 

21 

13 

Cubebs  and  inj.  arg.  nit. 

4 

22 

Ditto. 

8 

37 

Cauteriz.  and  copaiba. 

— 

14 

Cauteriz. 

17 

35 

Cauteriz.  inj.  cubebs. 

12 

22 

Inject,  ami  copaiba. 

— 

29 

Cauteriz.  cubebs. 

8 

22 

Inject,  arg.  nit. 

— 

41 

Inject,   plumb,  diac.  co- 

42 

21 

Inject,    zinc  sulph.  and 

paiba. 

copaiba. 

'Op.  citat.,  p.  16. 


1  Months. 


118 


ON    GONOKRIKEA. 


TABLE  VHI. 

Cases  treated  by  Judd,  showing  the  duration  of  Treatment  under  various  kinds 

of  Injections. 


Names. 

Substances  used. 

No.  of  days. 

s 

-8 

SoL  liq.  plumb,  and  ext.  belladonnas. 

((                  11                 «                  «                  (C 
(I                 (I                 (C                 ((                  <( 
((                   <(                   (C                   ((                   « 

Tinct.  ferri  c.  aqua. 

<(         «         « 

(C                 tt                  (( 

"        "        "        cubebs  and  copaiba. 
Sol.  arg.  nit. 
"        "       copaiba. 
Ext.  cubeb. 
Inj.  zinc,  sulpli.,  bals.  cop. 

Inj.  zinc,  sulph.,  bals.  cop. 

2 
5 
3 
5 
5 
4 
7 
6 
5 
7 
3 
By  twice  using 
injection,  in 
one  evening. 
1 

G 

t 

S 

A 

G 

t 

c 

-S 

H 

g 

W 

1 

MnD- 

A 

T 

-f 

B 

t 

K  
K- 

-e  

The  average  time  for  cure  is  much  below  anything  I  have  seen. 

Nitrate  of  Silver  Pastilles  (Soluble  Bougies). — In  the  first  edition  of  this 
work,  published  in  1852,  are  some  briefly  detailed  notices  of  attempts  to 
cure  obstinate  gonorrhoea  with  pastilles.  The  marked  effect  produced  by 
frequently  repeating  injections  led  me  to  hope  that,  if  the  action  of  such  a 
salt  as  the  nitrate  of  silver  could  be  kept  up  for  some  hours,  a  more  speedy 
cure  might  be  obtained.  For  this  purpose  pastilles  or  small  bougies,  con- 
taining sometimes  a  grain,  sometimes  half  a  grain,  of  the  nitrate,  mixed 
with  powdered  gum  arabic,  were  made  into  a  paste,  and  after  being  shaped 
like  a  small  bougie,  an  inch  and  a  half  to  two  inches  long,  were,  while  still 
soft,  oiled  and  introduced  into  the  urethra.  In  the  course  of  from  two  to 
five  hours  they  dissolved,  but  instead  of  effecting  any  improvement,  they 
either  produced  no  change  at  all,  or  else  brought  on  an  aphthous  state  of 
the  mucous  membrane,  such  as  is  often  seen  after  strong  injections  of  ni- 
trate of  silver  have  been  used,  and  equally  difficult  to  remove.  In  some 
instances  they  occasioned  such  discomfort,  that  the  patients  were  glad  to 
remove  them,  or  to  expel  them  by  making  water. 

Four  years  after  the  appearance  of  the  second  edition,  and  fourteen 
after  that  of  the  first  edition,  of  this  work,  mention  was  made  in  the  Mir- 
ror of  the  Practice  of  Medicine  and  Surgery '  of  the  use  of  soluble  bougies 
in  the  practice  of  Sir  Henry  Thompson,  who  was  trying  them  in  the  treat- 


1  Lancet,  vol.  i.,  p.  513.     1866. 


TREATMENT.  .  119 

ment  of  gonorrhoea  at  University  College  Hospital,  and  who  had  himself 
long  previously  informed  me  that  he  had  read  the  first  edition  of  this 
work,  where  he  must  have  seen  the  reasons  assigned  for  the  experiment. 
Some  short  time  after,  Mr.  Henry  Smith  stated  '  in  the  same  journal  that 
two  months  previously  Mr.  Cooper,  of  Oxford  Street,  had  suggested  to 
him  the  idea  of  employing  the  substances  used  for  injections  in  gonor- 
rhoea in  the  form  of  bougies  of  cacao  butter  ;  and  again,  subsequently  to 
this,  a  letter  appeared  ~  from  Mr.  Edgar  Browne,  of  Liverpool,  saying  that 
he  had  used  such  bougies  before  either  Mr.  Smith  or  Sir  Henry  Thomp- 
son, and  that  he  was  led  to  do  so  from  observing  the  beneficial  effects  of 
bougies  smeared  with  lard  ointment  or  medicated  glycerine.  Sir  Henry 
Thompson  pointed  out,  in  reply  to  Mr.  Browne,  that  medicated  bougies 
made  of  wax,  in  which  some  active  chemical  agent  had  been  dissolved, 
were  used  even  before  the  time  of  Wiseman.  From  this  time  forth,  a 
passing  extract  from  some  foreign  periodical  excepted,  the  subject  dis- 
appears from  the  English  journals.  The  idea  was,  however,  as  we  shall 
see  directly,  eagerly  caught  up  in  Germany. 

The  material  used  for  the  bulk  of  the  bougie  was,  in  Sir  Henry 
Thompson's  experiments,  cacao  butter,  which,  as  it  melts  at  a  tempera- 
ture of  100°  Fahrenheit,  is  perhaps  the  best  that  could  have  been  selected. 
The  other  ingredients  experimented  with  were,  for  each  bougie,  a  quarter 
of  a  grain  of  nitrate  of  silver,  a  grain  of  tannin,  two-thirds  of  a  grain  of 
acetate  of  lead  or  ten  grains  of  nitrate  of  bismuth  as  astringents,  and  two 
grains  of  belladonna  or  opium  as  a  sedative.  The  walls  of  the  urethra 
were  pressed  against  the  bougie  by  means  of  a  pad  of  Taylor's  stout  lint 
and  a  slip  of  adhesive  plaster,  with  the  view  of  squeezing  the  melted  bou- 
gie into  the  lacunae  of  the  urethra.  Judging  from  the  recorded  effects,  I 
am  of  opinion  that  the  pastilles  are  cleanlier,  and  that  usivther  can  be  con- 
sidered very  efficacious. 

Mr.  Watson  Cheyne,  considering  that  the  lingering  of  organisms  in 
the  urethra  may  satisfactorily  account  for  the  continuing  of  the  disease, 
has  tried3  the  effect  of  destroying  these  by  means  of  antiseptic  soluble 
bougies,  containing  five  to  ten  grains  of  iodoform  and  ten  grains  of  euca- 
lyptus oil,  followed  by  injections  of  boracic  acid  or  eucalyptus  emulsion, 
and  with  the  same  unvarying  good  fortune  which  seems  to  wait  on  all 
essays  of  this  nature.  In  four  or  five  days  the  discharge  becomes  mucous, 
and  ceases  altogether  in  a  week  or  ten  days  ;  there  being,  I  presume, 
neither  failures,  complications,  nor  after-results ;  while  Mr.  Brindley 
James 4  seems  to  have  been  a  trifle  more  successful  than  even  Mr.  Cheyne, 
his  patients  getting  well  in  about  a  week.  Yet,  gratifying  as  such  success 
may  be,  we  must,  when  we  remember  that  Dr.  Morris  cured  two-and- 

1  Lancet,  vol.  i.,  p.  674.  1866.  *Ibid.,  p.  724. 

1  British  Medical  Journal,  vol.  ii.,  p.  124     1880.  'Ibid.,  p.   166. 


120  ON    GONORRHCEA. 

twenty  cases  at  a  single  sitting,  decide  that  we  have  arrived  at  finality, 
and  that  any  further  essays  with  soluble  bougies  are  a  meaningless  waste 
of  human  time  and  talent. 

3.  Glycero- Tannin  Rods. — Professor  Sigmund  tried  the  bougies  in  four 
cases,  but  with  unfavorable  results.1  Dr.  Schuster  also  made  some  at- 
tempts with  them,8  but  found  that  the  plaster  by  which  they  are  kept  in 
is  troublesome  to  apply,  while,  if  it  slip  off,  the  cacao  butter  dirties  the 
patient's  linen  in  a  very  unpleasant  way.  He  therefore  substituted  glyce- 
ro-tannin  rods,  three  to  four  inches  long,  which  could  be  pushed  right 
down  the  urethra.  These  rods  are  well  rounded  at  the  end,  and  each 
one  contains  two  grammes  of  tannic  acid,  twelve  centigrammes  of  opium, 
and  sufficient  glycerine  to  make  these  ingredients  up  into  a  proper  con- 
eistence.  They  are  prepared  for  use  by  dipping  in  hot  water,  and  are 
only  kept  in  the  urethra  five  to  ten  minutes.  These  rods  seem  to  have 
acted  very  well  in  Dr.  Schuster's  practice,  curing  the  cases  quickly,  and 
not  bringing  on  either  orchitis,  inflammation  of  the  neck  of  the  bladder, 
of  the  bladder,  or  prostate. 

Tomowitz,  however,  who  tried  the  rods  in  fifty  cases,3  did  not  find 
them  so  easy  to  introduce  as  the  readers  of  Dr.  Schuster's  paper  might 
imagine,  or  more  efficacious  in  acute  gonorrhoea  than  ordinary  treatment, 
but  more  useful  than  the  latter  in  cases  of  gleet ;  and  Dr.  Adolf  Stern, 
who  gave  Schuster's  plan  a  fair  trial  in  a  large  number  of  cases,4  never  in 
a  single  instance,  where  he  watched  the  patient  closely,  achieved  the  cure 
of  acute  gonorrhoea  in  less  than  four  weeks.  Often  the  time  required  was 
from  five  to  eight  weeks,  so  that  in  respect  to  shortness  of  duration  he  did 
not  find  it  in  any  way  superior  to  injections.  He  had  no  better  success 
with  the  rods  in  gleet,  and  never  once  noticed  any  of  the  wonderfully  rapid 
cures  related  by  Dr.  Schuster.  He  found  that  the  rods,  though  easy 
enough  to  introduce,  were  difficult  to  make,  and  left  stains  on  the  linen 
which  could  not  be  effaced.  He  very  properly  condemns  Dr.  Schuster's 
proposal  to  use  them  twice  a  day  as  impracticable,  but  agrees  with  him  in 
observing  that  their  employment  is  not  followed  by  orchitis,  the  only  point 
on  which  the  two  observers  are  in  accord  with  each  other. 

Dr.  Oidtmann,  of  Linnich,  has  tried  a  very  similar  mode  of  practice,5 
or  rather  one  which  might  be  described  as  more  akin  to  the  armed  bougie, 
using  bougies  smeared  with  a  compound  of  Goulard  water,  lunar  caustic 
and  spermaceti  ointment,  and  afterward  dipped  in  a  mixture  of  cod-liver 
oil  and  glycerine,  the  paste  thus  formed  being  left  in  the  urethra.  Dr. 

1  Der  practisclie  Arzt.     Quoted  in  Practitioner,  vol.  i.,  p.  373.     1869. 
'Archiv  fur  Dermatologie,  B.  ii.,  S.  176. 

3  Allgem.  milit.  iirztl.  Zeit.,  No.  46.    1870.     Quoted  in  Archiv  fur  Dermatologie,  B. 
iii.,  S.  41. 

4  Archiv  fur  Dermatologie,  B.  v.  S.,  502. 

5  Der  practische  Arzt.,  9.     1868.     Quoted  in  the  Practitioner,  384.     1868. 


TREATMENT.  121 

Oidtmann  speaks  of  this  method  as  curing  rapidly  and  without  pain.  The 
injection  of  starch  and  glycerine,  mixed  to  a  creamy  consistence,  recom- 
mended by  M.  Paillasson,  may  rank  in  the  same  category.  Of  both  plans, 
however,  I  find  no  later  notice.  The  reporter  of  the  London  Medical 
Record,  commenting '  upon  an  account  by  Dr.  Lorey  of  the  cure  of  twenty 
successive  cases  by  means  of  gelatine  and  gum  bougies  containing  some 
therapeutic  ingredient,  probably  sulphate  of  zinc,  says  that  an  extensive 
trial  of  them  at  the  Lock  Hospital  showed  that,  though  occasionally  useful 
in  gleet,  they  are  more  uncertain  than  injections,  and  sometimes  cause  great 
irritation.  In  two  cases  swelled  testicle  came  on,  and  in  several  the  dis- 
charge, which  had  stopped  under  their  use,  returned  as  soon  as  they  were 
left  off. 

And  now,  in  order  to  bring  into  as  narrow  a  focus  as  possible  the  argu- 
ments for  and  against  all  the  systems  of  treatment  as  yet  discussed,  I  shall 
try  if  I  can  reduce  them  to  a  few  aphorisms,  in  which,  indeed,  if  I  could,  I 
would  have  written  the  whole  work  ;  for  I  imagine  that  men  like,  above  all 
things,  not  only  to  see  at  a  glance  what  an  author  has  borrowed  and  what 
he  has  found  out  for  himself,  but  to  find  his  meaning  tersely  and  clearly  ex- 
pressed ;  and  in  no  way  can  this  process  be  made  so  easy  as  by  condensing 
his  views  into  these  compact  forms  of  speech  which,  "  except  they  should 
be  ridiculous,  cannot  be  made  but  of  the  pith  and  heart  of  sciences."  The 
conclusions,  then,  which  I  venture  to  draw,  are — 

1.  That  all  the  remedies  yet  enumerated,  though  adequate  to  cure  by 
far  the  greater  number  of  cases,  still  leave  many  unrelieved. 

2.  That  while  many  are  undoubtedly  valuable,  some  of  them  are  disa- 
greeable, some  dangerous,  and  some  superfluous. 

3.  That  there  are  no  rules  to  guide  us  in  distinguishing,  at  the  outset, 
those  cases  which  are,  from  those  which  are  not,  amenable  to  these  reme- 
dies. 

4.  That  where  so  large  a  list  of  remedies  is  given,  some  attempt  ought 
to  be  made  to  decide  with  accuracy  in  what  cases  each  remedy  should  be 
tried  ;  which  as  yet  has  not  been  done,  so  that  every  cure  obtained  is  only 
an  additional  source  of  confusion. 

5.  That  the  reputation  of  injections  has  been  injured  by  the  want  of 
any  certain  rules  as  to  the  relative  value  of  the  different  substances  em- 
ployed, and  the  strength  requisite  in  different  cases  ;  thus  leading  to  the 
indiscriminate  application  of  different  substances  in  solutions  of  the  same 
strength  on  the  one  hand,  and  on  the  other,  to  the  equally  indiscriminate 
application  of  injections  of  the  same  strength  to  cases  not  equally  fitted  to 
bear  them. 

6.  That  the  treatment  has  been  made  secondary  to  disputes  about  the 
nature,  sources,  and  history  of  this  disease,  and  to  speculations,  for  they 

1  1873,  p.  362. 


122  ON    GONOKEIKEA. 

deserve  no  better  title,  about  the  action  of  medicines  ;  whereas  the  cure 
of  disease  ought  to  precede  all  other  considerations  ;  for  however  great 
may  be  the  value  of  science,  the  welfare  of  man  is  a  still  greater  object. 

7.  That  rash  as  such  an  opinion  may  seem,  I  do  not  fear  to  say,  that  I 
doubt  whether  man  will  ever  discover  drugs  superior  in  their  power  over  this 
disease  to  those  we  already  possess,  and  that  there  is  accordingly  more  to  be 
hoped  for  by  trying  to  improve  the  administration  of  medicines  already 
known  to  us,  than  in  seeking  for  new  remedies. 

I  have  spoken  plainly  on  this  topic.  The  trite  generalities,  the  inces- 
sant repetitions,  the  falling  back  upon  authorities  and  general  principles, 
practised  by  some  authors,  may  be  very  orthodox ;  but  they  do  not  satisfy 
our  mental  cravings,  they  do  not  give  us  what  we  want.  Writers  now  and 
then  express  themselves  so  very  guardedly,  that  it  is  as  difficult  to  arrive  at 
a  certain  knowledge  of  what  their  opinions  really  are  as  it  is  to  make  out  • 
those  of  a  Greek  chorus. 

Proposed  Plan  of  Treatment.  A.  In  the  Male.  — After  this  preliminary 
discussion  the  reader  will  naturally  inquire  whether  I  have  anything  better 
to  offer  in  its  stead.  I  reply  that  I  must  leave  that  point  to  his  decision. 
In  the  meanwhile  I  beg  to  submit  for  examination,  first  of  all,  a  plan  of 
abortive  treatment,  and  to  demonstrate  the  results  it  seems  to  offer.  To  do 
this  properly  I  must  first  ask  permission  to  divide  ah1  cases  of  gonorrhoea 
into  two  classes,  viz.,  those  which  admit,  and  those  which  do  not  admit, 
of  such  a  plan. 

Abortive  Treatment.  — Those,  then,  which  seem  most  adapted  for  it  are — 

1.  Cases  where  the  patients  present  themselves  before  great  pain  and 
running  have  set  in. 

2.  Patients  who  have  had  gonorrhoea  previously,  and  in  whom  the  pre- 
sent attack  does  not  appear  to  be  very  severe. 

3.  Those  cases  where  the  patient  is  desirous  of  an  immediate  cure  at 
any  price,  and  would  rather  go  through  anything  for  a  day  or  two  than 
have  a  long  illness. 

And  before  going  into  the  details  I  must  digress  for  a  few  minutes  to 
combat  an  opinion  which  seems  very  prevalent,  and  which  is,  that  M. 
Ricord  is  constantly  in  the  habit  of  using  an  abortive  treatment  of  a  simi- 
lar kind  ;  or,  in  other  words,  of  preluding  ah1  measures  with  a  strong  in- 
jection of  nitrate  of  silver.  This  may  be  an  incorrect  assumption,  as  I 
have  no  written  authority  for  it,  but  I  know  I  have  repeatedly  heard  it 
stated,  both  in  private  and  public,  without  contradiction.  Now  nothing 
could  be  wider  of  the  mark.  M.  Ricord's  abortive  treatment,  as  laid  down 
in  his  Traite  Pratique,1  consists  of  rest,  low  diet,  and,  where  there  is  pain, 
thirty  or  forty  leeches  to  the  perineum,  followed  by  copaiba  or  cubebs  and 
mild  injections  of  nitrate  of  silver  ;  and  he  expressly  confines  his  recom- 

1  P.  707. 


TREATMENT.  123 

mendation  of  a  strong  solution  of  this  salt  to  those  cases  which  begin 
"  without  pain,  without  any  sign  of  inflammation."  By  means  of  leeches 
used  in  this  way,  and  cubebs,  he  sometimes  cures  the  disease  in  three  or 
four  days,  and  generally  in  fifteen  to  twenty.  When  the  disease  begins 
without  pain  he  gives  drastic  purgatives,  sometimes  with  astringent  injec- 
tions. To  the  best  of  my  knowledge  it  was  Debeney  and  the  Irish  sur- 
geons mentioned  by  Carmichael '  who  first  introduced  the  practice  of  try- 
ing to  cut  short  gonorrhoea  by  giving  a  strong  injection  of  nitrate  of  silver. 

Before  taking  a  single  step  it  is  indispensably  necessary  to  ascertain 
whether  the  patient  can  rest  for  the  entire  day  after,  and  if  not  whether  he 
is  disposed  to  suffer  considerable  inconvenience.  If  he  be  unable  or  un- 
willing to  do  either,  it  is  best  at  once  to  lay  aside  all  thoughts  of  an  abor- 
tive cure  and  refer  the  case  to  the  second  class. 

But  if  this  co-operation  on  his  part  can  be  obtained,  the  abortive  treat- 
ment may  at  once  be  commenced.  The  patient  should  make  water,  and 
the  surgeon  then  injects  him  with  a  solution  of  nitrate  of  silver  containing 
five  grains  to  an  ounce  of  distilled  water.  The  syringe  used  should  be  that 
spoken  of  in  the  section  on  syringes.  By  limiting  the  strength  of  the  solu- 
tion to  five  grains  we  avoid  the  severe  pain  which  is  caused  by  the  strong 
solutions  of  this  salt,  and  by  retaining  the  injection  in  the  urethra  for  two 
or  perhaps  three  minutes  we  can,  in  almost  every  case,  attain  any  useful 
purpose  likely  to  be  served  by  a  more  concentrated  solution.  M.  Diday 
advises 2  that  the  injection  should  be  kept  in  for  five  minutes. 

The  deep  burning  pain  which  now  ensues  is  widely  different  from  that 
produced  by  the  salts  of  zinc,  and  is  often  accompanied  by  flushes  of  heat 
which  thrill  through  the  frame.  It  is,  however,  generally  soon  relieved  ~bj 
bathing  the  penis  with  hot  water,  and  a  hot  bath  will  for  the  most  part 
effectually  remove  what  the  local  application  has  left  undone. 

The  next  step  is  to  prescribe  a  dose  of  calomel,  at  least  three  or  four 
grains,  followed  by  seidlitz  powders,  citrate  of  magnesia,  or  draughts  of 
salts  and  senna  every  two  hours  until  several  loose  stools  are  procured. 
The  bowels  should  be  completely  scoured  out,  and  no  food  allowed  except 
a  little  warm  tea  or  gruel,  with  toast,  to  assist  the  action  of  the  medicines. 
The  citrate  of  magnesia  is  unquestionably  the  most  agreeable,  and  I  fancy 
it  is  quite  as  efficacious  as  the  others. 

After  every  stool  the  patient  should  inject  with  a  solution  of  sulphate 
of  zinc  from  three  to  five  grains  in  the  ounce.  The  injection  is  to  be  kept  in 
contact  with  the  mucous  membrane  till  a  slight  sense  of  burning  is  induced, 
when  it  may  at  once  be  withdrawn.  The  penis  should  be  bathed  each  time 

1  An  essay  on  Venereal  Disease.  By  Richard  Carmichael,  M.R.I.A.  P.  111.  They 
used  an  injection  of  ten  or  twelve  grains  to  an  ounce  ;  Carmichael,  himself,  however, 
strongly  deprecates  the  practices. 

5  Therapeutique  des  Maladies  Veneriennes,  p.  9.     1876. 


124  ON    GONOREHCEA. 

•with  water  as  hot  as  it  can  be  borne  ;  and  the  greater  the  heat  the  more 
complete  the  relief,  not  only  to  the  pain  produced  by  injecting,  but  also  to 
the  scalding,  weight,  etc. 

Dr.  Niddrie  advises  '  injecting  in  much  the  same  way  twice  every  half 
hour,  employing,  the  first  day,  cold  water,  and  the  second  sulphate  of  zinc 
solution,  and  seems  to  have  had  great  success.  Dr.  William  Colles  injects 
every  half  hour/  as  does  Mr.  Berkeley  Hill,  using,  however,  tepid  water,  and 
when  the  congestion  is  moderate  and  the  irritation  not  too  great,  hourly 
injections  of  alum  or  zinc.  I  have  never  carried  the  system  quite  so  far  as 
this,  but  I  have  repeatedly  known  patients  give  themselves  six  or  seven 
injections  in  a  day  with  good  results. 

The  next  day  the  discharge  is  generally  thin  and  small  in  quantity,  the 
symptoms  of  inflammation  have  disappeared,  and  the  cure  is  mostly  com- 
pleted in  a  day  or  two  by  the  use  of  the  same  means  ;  the  patient  using 
the  injection  every  time  he  makes  water,  and  gradually  raising  the  strength 
of  it  till  it  reaches  ten  grains  to  an  ounce.  Mild  aperients  and  low  diet 
may  also  be  continued.  When  this  plan  fails,  the  case  may  be  referred  to 
the  second  class,  for  I  believe  that  abortive  treatment,  to  succeed  at  all 
must  succeed  at  once. 

The  reader  must,  however,  bear  in  mind  that,  as  I  have  already  said, 
and  as  I  stated  in  the  first  edition  of  this  work,  but  few  cases  comparatively 
admit  of  this  treatment.  I  believe  those  who  have  tried  it  and  have  looked 
into  the  results  are  agreed  on  this  point.  Dr.  JBumstead  says,3  "  Taking 
the  usual  run  of  cases  as  met  with  in  practice,  probably  not  one  out  of  ten 
is  seen  at  a  sufficiently  early  period  to  admit  of  the  abortive  treatment ; " 
and  Dr.  Durkee  considers  *  that  the  number  of  cases  in  which  it  can  be 
employed  must  necessarily  be  very  small,  and  that  if  the  discharge  have 
lasted  more  than  a  day  and  a  night  the  time  for  making  trial  of  it  has 
passed. 

Ordinary  Treatment, — Every  other  case  of  gonorrhoea,  every  case  in 
which  the  abortive  treatment  has  failed,  or  in  which  it  cannot  be  applied, 
and  every  case  accompanied  by  excessive  pain  and  irritability  of  the  ure- 
thra, or  of  long  standing,  and  attended  by  fixed  pain  on  the  under  surface 
of  this  canal,  may  be  placed  in  the  second  class.  It  is  to  these  that  I  wish 
to  apply  a  new  treatment,  substituting  for  the  means  usually  employed 
certain  salts  of  potass  with  aperients  and  injections  so  combined,  graduated, 
and  applied,  as  to  act  efficiently  but  without  much  pain,  over  the  whole  of 
the  diseased  surface. 

After  a  great  number  of  experiments  I  am  disposed  to  think  that  in  all 
but  very  severe  cases  the  acetate  of  potass,  in  combination  with  spirit  of 
nitric  ether,  is  one  of  the  most  potent  internal  remedies  I  have  met  with. 

1  Lancet,  vol.  i.,  p.  357.    1852.          s  Dublin  Quarterly  Journal,  vol.  xxxv.,  p.  2. 
3  Op.  citat.,  p.  78.  «  Op.  citat.,  p.  34. 


TREATMENT.  125 

The  best  proportions  seem  to  be  five  drachms  of  acetate  of  potass  with 
three  drachms  of  spirit  of  nitre,  and  half  an  ounce  of  compound  spirit  of 
juniper,  or  two  or  three  drachms  of  spirit  of  nutmeg,  in  a  six-ounce  mix- 
ture, employing  as  a  vehicle  almost  anything  the  patient  likes,  camphor 
mixture  and  mint-water  being  perhaps  among  the  best.  In  more  severe 
cases  the  chlorate  of  potash  may  be  added,  and  in  those  of  unusual  severity 
I  should  recommend  beginning  with  it  at  once.  As  many  failures  at- 
tended my  first  attempts  to  discover  an  available  form  of  prescription,  I 
give  one  which  I  believe  to  be  the  most  useful. ' 

Along  with  these  medicines  I  would  always  recommend  a  free  use  of  the 
pills  given  belowr, 2  when  the  bowels  are  only  acted  upon  with  difficulty. 
They  should,  I  think,  always  be  given  to  such  an  extent  as  to  induce  two  or 
three  loose  stools  daily.  When  they  do  not  act  freely  enough,  a  teaspoonful 
or  two  of  citrate  of  magnesia,  a  seidlitz  powder,  a  tablespoonful  of  any  sa- 
line mixture,  or  a  wineglassful  of  Friederichshall  water,  may  be  given  the 
following  morning. 

When  one  of  these  solutions  is  taken  regularly,  supposing  it  is  suited  to 
the  case,  an  alteration  in  the  discharge  is  soon  noticed,  indeed  within  forty- 
eight  hours  it  is  materially  diminished,  becoming  at  the  same  time  thinner, 
less  colored,  and  more  mucous.  This  effect  seems  to  be  produced  with 
equal  rapidity  in  cases  of  long  standing  and  recent  ones,  in  women  and 
in  men  ;  potass  being  perhaps  one  of  the  true  antiphlogistics  in  infiamv 
mations  of  this  kind.  So  far  as  I  know,  every  surgeon  who  has  given 
these  medicines  a  fair  trial  has  admitted  their  power.3  Their  use'  has  been 
attended  with  much  less  chordee,  and  has  not  been  followed  by  irrita- 
ble bladder  or  swelled  testicle  in  more  than  a  few  instances  out  of  all  the 
cases  I  have  treated  for  many  years,  whereas,  under  the  old  plans,  these 
annoying  complications  were  very  frequent.  Generally,  too,  the  weight  felt 
about  the  testes,  the  scalding  and  pain  on  making  water,  quickly  grow 
milder  under  their  influence. 

It  is  scarcely  ever  requisite  to  continue  the  potass  mixture  more  than 
ten  days,  and  I  seldom  keep  it  up  beyond  a  week  ;  what  good  it  can  do  it 
usually  effects  in  that  time,  and  generally  by  then  the  symptoms  are  so  far 
subdued,  that  it  is  difficult  to  persuade  the  patient  to  go  on  with  treatment 
at  all.  Indeed,  speaking  at  hazard  it  may  be  assumed  that  at  this  time  three 
patients  out  of  four  bring  on  a  relapse  by  some  imprudence  ;  however,  it 
is  seldom  necessary  to  do  more  than  to  resume  the  old  treatment,  the  potass 
mixture  being  now  given  for  only  three  or  four  days.  At  the  same  time  the 

1  $ .  Potassae  chloratis,  3  ij. ;  aquae  destill.  bull.,  ^  iv.    M.  et  agita  bene  donee  solutio 
ft.  dein  adde  potassae  acetatis,  3  ij.  ;  spir.  juniper.,  §  ss.  ;   mist,   camph.  ad.,  §  vj.      M. 
Coch.  amp.  duo  bis  quotidie  sumenda. 

2  3-  Pil-  colocynth.  comp. ,  3  ss. ;  —  hydrargyri,  3ss.  ;  ext.  hyoscyami,  3j.     M.  ft. 
pil.  xij.     Sumat  j.  vel  ij.  hor.l  decubitura. 

1  Langston  Parker's  Modern  Treatment  of  Syphilis,  p.  67.    1860. 


126  ON    GONORRH(EA. 

patient  may  as  well  be  warned  that  the  relapse  is  generally  more  difficult  to 
manage  than  the  original  disease.  From  giving  any  specific  medicines  after 
these  potass  preparations  I  have  never  seen  the  least  benefit,  but  the  patient 
gets  on  the  better  for  having  recourse  to  the  aperient  pill,  supplemented 
occasionally  by  a  mild  dose  of  some  saline  aperient  before  breakfast.  When 
he  is  weak  and  low,  there  is  no  harm  in  his  taking  a  little  acid  and  bitter, 
quinine,  or  forty  to  sixty  minims  two  or  three  times  a  day  of  Thomas's  tinct- 
ure of  the  sesquichloride  of  iron,  it  being,  however,  quite  understood  that 
such  remedies  possess  no  control  over  the  purulent  running. 

These  medicines  I  have  now  used  for  some  years  without  seeing  any  case 
resist  their  influence,  except — 1,  when  there  was  stricture  ;  2,  a  tight,  irri- 
table state  of  the  urethra  ;  and  3,  when  the  disease  was  of  long  standing  and 
strong  injections  had  been  used,  the  patient  all  the  while  suffering  from  a 
fixed  pain  in  the  under  part  of  the  urethra,  generally  near  the  froenum,  but 
sometimes  obscure  as  to  its  true  seat.  Even  many  of  these  cases  were 
materially  benefited,  but  it  was  necessary  also  to  have  recourse  to  further 
measures.  It  should,  however,  be  thoroughly  understood,  that  I  do  not 
speak  of  them  as  either  infallible,  or  adequate  of  themselves  to  cure  the 
disease. 

So  long  as  the  heat  in  the  penis  and  scalding  trouble  the  patient,  so  long 
should  he  resort  to  the  frequent  use  of  hot  water  in  the  way  mentioned  in 
speaking  of  the  abortive  treatment. 

In  most  cases  this  treatment  will  not  succeed  unless  it  be  seconded  by 
injections.  In  order  to  make  the  action  of  these  as  perfect  as  possible,  care 
must  be  taken — To  select  a  solution  of  such  a  strength  as  to  act  on  the 
mucous  membrane.  2.  To  apply  it  over  the  whole  of  the  diseased  surface. 
3.  To  see  that  it  is  producing  no  injury. 

Although  I  have  such  a  very  high  opinion  of  the  nitrate  of  silver,  still  I 
do  not  think  it  is  a  good  plan  to  trust  the  patients  with  it,  for  they  are  apt, 
in  their  anxiety  to  hasten  the  cure,  to  make  over-free  use  of  the  remedy, 
and  induce  a  state  of  matters  very  difficult  to  set  right  again  ;  generally  in- 
dicated by  .a  sanious  discharge,  fixed  pain  in  the  under  surface  of  the  urethra, 
and  sometimes  even  an  aphthous  state  of  the  mucous  membrane.  Besides 
this,  it  stains  the  patient's  hands  and  linen,  the  floor,  carpet,  etc.  It  re- 
quires a  complete  and  rather  expensive  apparatus,  so  that,  upon  the  whole, 
it  is  best  for  the  surgeon  to  use  it  himself.  The  stains  spoken  of  may  be 
removed  from  colorless  materials  without  any  injury,  but  it  is  very  diffi- 
cult to  efface  them  without  discharging  colors,  especially  delicate  ones. 
The  shortest  way  is  simply  to  rub  them  over,  after  wetting  them,  with  the 
cyanogen  soap  made  by  Mr.  Thomas,  of  Pall  Mall,  or  to  apply  a  solution  of 
cyanide  of  potassium. 

The  nitrate  of  silver  should  be  used  every  day  till  the  discharge  has 
ceased  ;  for  the  plan  to  be  pursued  after  this  instructions  are  given.  As 
regards  the  strength  of  the  injection,  the  safest  way  is  to  begin  with  a  so- 


TREATMENT.  127 

lution  of  an  eighth  to  half  a  grain  to  an  ounce,  according  as  the  patient  is 
known,  or  seems,  to  be  very  sensitive  as  to  pain  or  not,  and  raise  it  gradu- 
ally to  a  strength  of  not  less  than  two  or  more  than  ten  grains  to  an  ounce. 
I  have  sometimes  met  with  a  case  where  the  patient  could  never  bear  more 
than  a  grain  to  the  ounce,  and  yet  did  very  well.  There  is  one  golden  rule 
for  deciding  how  much  is  to  be  done  at  a  time.  A  slight  feeling  of  heat, 
for  a  quarter  of  an  hour  or  twenty  minutes  after  giving  an  injection,  is  all  that 
is  requisite. 

When  this  injection  has,  from  some  idiosyncrasy,  produced  a  greater 
amount  of  pain  than  was  expected ;  when  the  patient  has  been  using  too 
strong  injections  previous  to  his  first  visit ;  when  there  is  reason  to  sus-( 
pect  that  stricture  is  coming  on  ;  when  there  is  an  aphthous  state  of  the 
urethra,  or  discharge  of  blood  or  bloody  serum  from  this  channel,  it  is 
better  in  all  cases  to  suspend  injections,  or  to  use  them  very  sparingly,  till 
these  symptoms  subside,  when  they  may  safely  be  resumed.  Whenever, 
too,  it  is  observed  that  distending  the  urethra,  however  gently,  by  retain- 
ing the  injection  gives  pain,  this  should  be  at  once  discontinued,  and  the 
fluid  should  be  simply  allowed  to  trickle  from  behind  forward  over  the 
inflamed  part. 

In  conjunction  with  the  nitrate  of  silver,  given  by  the  surgeon,  the  sul- 
phate of  zinc,  along  with  the  chloride,  may  be  used  by  the  patient  himself, 
commencing  with  one  to  two  grains  of  the  former,  and  a  quarter  to  half  a 
grain  of  the  latter,  in  an  ounce  of  water,  gradually  increasing  the  strength 
of  the  solution,  so  as  just  to  keep  up  the  same  amount  of  action  as  at  first, 
and  no  more.  The  addition  of  ten  or  fifteen  minims  of  spirits  of  camphor 
to  each  ounce  of  the  solution  has  often  appeared  to  increase  the  efficacy  of 
the  injection.  How  it  acts  I  will  not  venture  to  say  ;  I  only  know  that  its 
operation  is  generally  beneficial,  which  is  to  my  thinking  of  greater  conse- 
quence. WThen  the  chloride  is  prescribed,  a  little  mucilage  should  be 
added,  to  prevent  flocculence  in  the  solution.  As  with  the  other  injections, 
this  should  never  be  carried  to  the  extent  of  inducing  pain ;  the  utmost 
that  is  required  is  a  slight  sense  of  heat  for  ten  or  fifteen  minutes.  But  if 
it  is  to  be  of  any  service  this  degree  of  action  must  be  attained,  however 
strong  a  solution  may  be  required. 

The  patient  should  always  make  water  before  injecting,  and  with  a  little 
perseverance  he  will  generally  be  able,  after  an  effort  or  two,  to  evacuate 
some  fluid  from  the  bladder.  When  this  precaution  is  taken,  we  avoid  not 
only  the  hazard  of  the  injection  being  washed  out  prematurely  by  the 
stream  of  urine,  but  also  of  its  being  prevented  by  the  purulent  discharge 
from  coming  in  contact  with  the  mucous  membrane.  Besides,  this  prac- 
tice conduces  greatly  to  the  patient's  comfort,  as  the  passing  of  the  urine 
over  a  recently  injected  surface  is  often  very  disagreeable. 

Many  surgeons  think  it  necessary  to  change  one  injection  which  is 
doing  no  good  for  another,  on  the  chance  that  it  may  be  of  service,  "  ring- 


128  ON    GONORKHCEA. 

ing  the  changes  on  them  frequently,"  as  one  author  puts  it.  Mr.  Johnson1 
and  Mr.  Philip  Foster2  advocate  this  plan,  as  did  Sir  Astley  Cooper,3  and 
Mr.  Noble  Smith  holds 4  that  the  great  secret  in  using  injections  is  to 
"  vary  them  sufficiently  ;"  Zeissl  even  maintains 5  that  we 
ought  never  to  use  the  same  injection  very  long,  as  the 
urethra  so  soon  gets  accustomed  to  it.  This  may  be  good 
practice,  but  it  does  not  tally  with  the  result  of  my  obser- 
vations, which  is,  that  if  the  injections  just  mentioned  will 
not  cure  the  disease,  no  remedy  of  this  kind  will ;  and  that 
when  one  substance  succeeds  where  others  failed,  it  simply 
means,  not  that  the  change  has  done  good,  but  that  that 
remedy  was,  from  the  very  beginning,  better  suited  to  the 
case.  But  supposing  the  opinion  of  these  gentlemen  to 
be  well  founded,  what  becomes  of  inductive  science  here, 
seeing  that  the  practice  is  about  as  purely  empirical  as  any- 
thing can  well  be  ? 

Syringes. — However  important  it  may  be  to  regulate  ex- 
actly the  strength  of  an  injection,  it  is  equally  indispensable 
that  the  fluid  should  come  into  contact  with  the  whole  of 
the  diseased  surface,  and  that  a  proper  quantity  should  be 
injected.  To  effect  this  the  syringe  employed  by  the  sur- 
geon must  be  furnished  with  a  pipe  quite  an  inch  and  a 
half  to  two  inches  long,  as  shown  in  the  engraving,  which 
is  the  exact  size  of  the  instrument.  I  often  use  one  more 
than  three  inches  in  length.  This  tube  should  be  made, 
either  of  platinum,  which  is  the  best  of  all  materials,  or  of 
silver  drawn  solid.  If  a  soldered  silver  tube  be  substi- 
tuted, it  becomes  in  the  long  run  nearly,  if  not  quite  as 
costly,  as  the  soldering  must  be  well  gilded,  and  the  gilding 
frequently  renewed,  otherwise  the  nitrate  will  soon  act  on 
it  Unless  this  precaution,  of  Jilting  the  syringe  with  a  pipe, 
be  taken,  injections  may  be  used  FOR  MONTHS  without  ever 
reaching  the  seat  of  the  discharge. 

All  the  syringes  I  have  seen  are  far  too  long  in  the  barrel, 
and  hence  somewhat  unmanageable.  It  is  not  every  person 
that  can  stretch  his  hand  so  as  to  reach  the  knob,  or  ring, 
of  the  piston,  and  at  the  same  time  grasp  the  cylinder  firmly. 
The  consequence  is  that  the  instrument  is  awkwardly  held, 
and  perhaps  dropped  and  broken  ;  moreover,  the  piston 
often  fits  badly  to  the  cylinder,  so  that  a  great  deal  of  the 
fluid  escapes  backward  ;  and  if  this  be  obviated,  the  patient  injects  far 

1  Op.  citat.,  p.  96.  *  Medical  Times  and  Gazette,  vol.  ii.,  p.  461.     1873. 

3  Lancet,  vol.  iii.,  p.  200.  4  Ibid.,  vol.  i.,  p.  780.     1871. 

s  Wiener  mediziuische  Wochenschrift,  S.  999.     1879. 


TREATMENT.  129 

too  great  a  quantity,  thus  causing  unnecessary  pain  and  distention  of  the 
canal,  to  which,  perhaps,  much  of  the  mischief  said  to  have  been  caused 
by  injections  might  with  reason  be  attributed. 

In  order  to  obviate  these  defects,  I  had  some  syringes  made  expressly 
for  patients  and  of  a  totally  different  construction.1  The  cylinder  and 
piston  are  not  above  half  the  ordinary  length,  so  that  a  much  greater  con- 
trol over  the  instrument  is  obtained.  The  cylinder,  when  the  piston  is  in, 
contains  about  two  drachms  of  fluid,  so  as  to  allow  for  loss  and  yet  leave  a 
sufficient  quantity.  The  pipe  is  made  of  silver,  two  inches  long,  extremely 
smooth,  and  of  the  diameter  of  a  No.  6  catheter.  Britannia  metal,  or  even 
ivory,  will  do  very  well  when  the  syringe  is  only  to  be  used  for  zinc  injec- 
tions. The  cylinder  should  always  be  of  glass,  even  where  expense  is  not 
an  object  and  more  costly  material  might  be  considered  an  advantage,  for 
the  patient  can  then  see  that  it  is  properly  charged  with  fluid  and  not 
chiefly  vrith  air,  as  I  have  often  known  occur  with  pewter  syringes ;  and 
in  order  that  no  fluid  may  escape  backward,  the  piston  should  be  overlaid 
with  worsted  or  wash-leather,  so  that  it  only  works  stiffly  at  first. 

With  this  syringe  the  patient  can  inject  over  the  whole  of  the  diseased 
surface.  The  penis  is  grasped  at  the  glans,  and  drawn  into  a  straight  line, 
the  syringe  introduced,  and  the  piston  is  then  driven  sharply  home.  As 
the  fluid  is  forced  into  the  urethra  the  syringe  should  be  withdrawn,  in 
order  that  no  part  of  the  canal  may  be  immoderately  distended  ;  the  glans 
should  be  kept  firmly  in  contact  with  the  pipe  till  it  is  withdrawn,  and 
then  compressed  at  the  meatus,  till  the  injection  produces  the  desired  ef- 
fect of  inducing  a  decided  feeling  of  warmth.  In  some  cases  accompanied 
by  a  very  unusual  tenderness  of  the  urethra,  it  is  a  good  plan  to  dip  the 
syringe  in  oil  for  the  first  day  or  two. 

When,  in  earlier  editions  of  this  work,  I  insisted  on  the  necessity  for 
earning  the  injection  a  good  way  down  the  urethra,  I  was  met  by  very 
decidedly  expressed  objections.  Since  then  the  principle  has  been  more 
than  once  recognized,  for  in  1867  we  find  Mr.  Grinfield  Coxwell  recom- 
mending2 syringes  with  tubes  two  and  a  half  inches  and  six  inches  long, 
pierced  at  both  points  and  sides,  as  highly  useful  in  gonorrhoea  and  gleet ; 
Dr.  Morgan  describing 3  a  syringe  composed  of  two  tubes  and  a  bottle,  the 
far  end  of  the  tube  leading  to  the  bottle  charged  with  the  injection  being 
taken  by  the  patient  between  his  teeth,  so  that  the  fluid  may  be  blown  a 
good  way  down  the  urethra  ;  Mr.  Durham  using4  an  elastic  ball  with  a 
vulcanite  tube  quite  three  or  three  and  a-half  inches  long,  and  so  on. 

Dr.  Bumstead  recommends,  that 5  while  the  injection  is  in  the  urethra, 

1  Made  by  Messrs.  Walters  &  Co..  of  29  Moorgate  Street,  and  exhibited  before  the 
Medical  Society  of  London,  May  28,  1853. 

-  Medical  Times  and  Gazette,  vol.  ii.,  p.  617.     1867. 

3  Dublin  Quarterly  Journal,  vol.  xlvii. ,  p.  358. 

4  Guy's  Hospital  Reports,  third  series,  vol.  xv. ,  p.  475.  *  Op.  citat. ,  p.  76. 

9 


130  ON    GONORRHOEA. 

"  a  finger  of  the  disengaged  hand  should  be  run  along  the  under  surface 
of  the  penis  from,  behind  forwards,  so  as  to  distend  the  portion  of  the 
canal  occupied  by  the  injection  and  insure  the  thorough  application  of 
the  fluid  to  the  whole  mucous  surface." 

It  is  all-important  that  the  surgeon  should  satisfy  himself  whether  the 
patient  understands  how  to  use  the  injection  ;  no  directions  will  ever  take 
the  place  of  this  precaution,  the  want  of  which  has  thrown  more  discredit 
on  injections  than  even  such  sequelae  as  stricture  and  orchitis  ;  I  have  con- 
stantly heard  patients,  especially  hospital  patients,  say  they  knew  how  to 
inject  themselves,  and  make  a  very  lamentable  exhibition  when  they  came 
to  show  off  their  skill.  The  fluid  slipped  back  between  the  piston  and 
barrel,  or  flowed  out  of  the  urethra  as  fast  as  it  flowed  in,  or  never  flowed 
in  at  all,  etc. 

I  trust  it  is  now  needless  to  say  that  it  is  quite  unnecessary  to  com- 
press the  urethra  behind  the  scrotum  in  order  to  prevent  the  injection 
from  passing  too  far  into  the  canal.  It  is  a  mystery  to  me  how  such  a  fear 
as  that  an  injection  could  get  into  the  bladder,  or  if  it  got  there  could  do 
the  least  harm,  ever  originated  ;  and  it  is  one  of  the  proofs  of  the  anxiety 
with  which  men  of  abilities  and  information  cling  to  traditions  and  pre- 
conceived theories,  which  five  minutes'  use  of  their  own  senses  would 
overthrow.  Howard  tells  '  his  readers  that  the  syringe  should  never  have 
a  long  tube.  Sir  Charles  Bell  actually  used  leather  shields  to  prevent 
more  than  the  tip  of  the  syringe  entering  the  urethra  ;3  and  Sir  Astley 
Cooper  recommended  a  similar  precaution,  though  neither  he,  strong  as 
he  was,  nor  any  one  else,  could  force  an  injection  into  the  neck  of  the 
bladder  with  the  common  syringe.  The  difficulty  is  to  get  it  in  far  enough. 

A  correspondent  of  the  Medical  Circular,3  speaking  of  this  paragraph, 
said  that,  with  a  common  pewter  syringe,  he  had  passed  an  injection  into 
the  bladder  more  than  a  hundred  times,  and  Dr.  Otis  has  known  three 
patients  able  to  inject  their  own  bladders  with  an  ordinary  syringe.4 
Since  then  the  possibility  of  this  occurrence  has  been  strongly  re-affirmed 
and  as  strongly  contested.  I  certainly  never  tried  to  force  fluid  into  this 
viscus,  and  therefore  I  ought  not,  perhaps,  to  have  denied  that  others  may 
have  succeeded  in  doing  so.  I  have,  however,  often  seen  patients  employ 
a  good  deal  of  force,  and  yet  fail,  and  I  have  used  almost  daily,  for  years 
past,  a  very  long  syripge,  reaching  to  the  membranous  part  of  the  urethra  ; 
but  although  the  injections  given  with  it  are  for  maladies  in  which  the 
urethra  is  much  less  irritable  than  in  gonorrhoea,  yet  I  generally  find  that 
every  drop  of  the  injection  is  expelled  so  soon  as  the  pressure  is  taken  off. 

I  have  frequently  seen  a  mild  injectioii  kept  in  the  canal  a  minute  or 
two,  and  then  thrown  out,  sometimes  suddenly,  at  other  times  slowly.  At 

1  Op.  citat.,  vol.  iii.,  p.  138.  2  Institutes  of  Surgery,  vol.  i. ,  p.  291. 

3  Vol.  ii.,  p.  218.     1859. 

4 New  York  Journal  of  Medicine,  vol.  i.,  p.  360.     1870. 


TREATMENT.  131 

first  I  thought  these  were  instances  of  injections  reaching  the  bladder,  but 
long  ago  arrived  at  the  conviction  that  the  occurrence  is  due  to  sudden 
contraction  of  a  segment  of  the  canal ;  for  if  an  injection  enter  the  bladder 
and  be  expelled,  the  urine  comes  with  it.  One  gentleman,  however,  quite 
capable  of  judging,  supports  the  position  I  have  taken  up.  "It  is,"  says 
Dr.  Bumstead,1  "absolutely  impossible  to  inject  the  bladder,  however 
great  the  amount  of  force  employed,  by  means  of  a  syringe  merely  intro- 
duced within  the  meatus  ;  "  and  what  holds  good  of  injecting  in  this  way  is 
quite  applicable  when  syringes  with  a  tube  two  inches  long  are  employed. 

Dr.  Bumstead  speaks  highly  of  the  syringes  made  by  the  American 
Hard  Rubber  Company.  In  these  instruments  the  diameter  of  the  cylinder 
is  in  all  parts  alike,  the  piston  fits  with  great  accuracy,  and  the  material 
employed  is  not  acted  on  by  any  of  the  substances  usually  prescribed  for 
injections.  Vulcanite  syringes  have  also  been  recommended.2 

The  surgeon  should  instruct  the  patient  as  to  the  best  method  of  pre- 
venting the  discharge  from  marking  his  linen.  All  oiled-silk  bags,  thick 
wrapping,  etc.,  heat  the  penis  too  much  and  dispose  to  chordee.  The 
simplest  and  lightest  application  I  know  of  is  the  following  :  When  the 
prepuce  is  short,  a  piece  of  thick  lint,  half  an  inch  long  and  a  third  of  an 
inch  broad,  or  a  layer  of  cotton  wool,  is  placed  over  the  orifice  of  the  ure- 
thra ;  the  end  of  a  strip  of  bandage,  a  foot  long  and  an  inch  broad,  is  then 
laid  on  the  under  surface  of  the  penis,  passed  over  the  lint  to  the  upper 
surface  of  the  penis  opposite  to  where  it  was  first  applied,  turned  on  itself, 
and  carried  twice  round.  It  may  then  be  secured  by  a  piece  of  worsted, 
or  a  very  thin  ring  of  galvanized  india-rubber.  An  old  towel  or  napkin 
affords  excellent  material  for  a  bandage,  and  the  lint  should  be  changed 
every  time  the  patient  makes  water.  When  the  prepuce  is  long  there  is 
no  need  for  any  bandage  ;  the  skin  is  simply  drawn  back,  the  cotton  or  lint 
placed  underneath  it,  and  it  is  then  drawn  forward  again.  Should  the  dis- 
charge be  very  profuse,  a  good  plan  is  to  tie  an  old  silk  handkerchief  round 
the  waist  and  let  it  hang  down  in  front. 

The  nitrate  of  silver  injection  is  used  regularly  till  the  discharge  ceases, 
and  for  three  days  after.  From  that  time  forth  it  is  given  only  every  sec- 
ond day,  and  can  even  usually  be  reduced  in  strength  ;  for  it  may  be  laid 
down  as  an  axiom,  that  the  necessary  effect  should  always  be  attained 
with  the  smallest  amount  of  material.  Generally,  at  the  expiration  of 
eight  days  from  the  last  appearance  of  any  morbid  secretion,  measures 
of  this  kind  can  be  safely  renounced.  On  the  other  hand,  when  the  dis- 
charge is  rebellious,  and  no  particular  pain  is  set  up  by  the  solution  which 
the  surgeon  is  using,  this  may  be  increased  in  strength.  The  rate  at  which 
this  can  be  safely  effected  is  scarcely  ever  alike  in  two  persons,  and  much 
must  therefore  be  left  to  the  surgeon's  discretion.  I  have  found  an  eighth 

'Op.  citat.,  p.  83.  s  British  Medical  Journal,  vol.  ii.,  p.  821.  1881. 


132 


ON    GONOEEH(EA. 


of  a  grain  enough,  and  I  have,  with  the  patient's  full  concurrence,  raised  it 
five  grains  at  a  time.  The  zinc  injection  is  continued  and  left  off  along 
with  the  nitrate,  but  from  the  time  that  the  discharge  has  stopped,  it  need 
not  be  employed  more  than  twice  a  day. 

I  have  never  been  quite  able  to  satisfy  myself  as  to  the  average  time 

cases  of  gonorrhoea  last  when  treated  in 
this  way.  A  great  many  get.  well  in  from 
four  to  fourteen  days,  but  again  I  have 
seen  a  careful,  attentive,  healthy  looking 
patient  little  if  any  better  at  the  end  of 
three  to  four  weeks  ;  and  one  gentleman, 
a  native  of  Australia,  had  scarcely  im- 
proved after  sixty-five  days  of  most  per- 
severing attendance. 

The  Long  Urethral  Syringe. — When 
the  symptoms  point  to  extension  of  the 
morbid  process  toward  the  membranous 
portion  of  the  canal,  recourse  should  be 
had  without  delay  to  an  instrument  which 
will  carry  the  fluid  as  far  along  the  ure- 
thra as  the  disease  itself  reaches,  and  this 
I  conceive  is  thoroughly  effected  by  the 
syringe  shown  in  the  annexed  engraving. ' 
It  consists,  as  the  reader  will  see,  of  a 
detached  tube  A,  which  is  oiled  at  the  tip 
and  passed  down  as  far  as  the  bulb,  mem- 
branous, or  even  the  prostatic  portion  of 
the  urethra,  as  may  be  found  requisite ; 
the  syringe  B,  charged  with  a  solution  of 
nitrate  of  silver,  is  inserted  into  the  end 
of  the  tube  and  pressed  firmly  in,  so  that 
the  two  parts  may  hold  well  together  ; 
the  piston  is  then  driven  home,  the  tube 
being  steadily  withdrawn  at  the  same 
time.  The  fluid  should  be  detained  in 
the  passage  by  compressing  the  urethra 
rather  low  down  in  the  penile  part  till  a 
sensation  of  heat  is  felt,  when  it  is  allow- 
ed to  escape.  To  prevent  after-leakage 
from  staining  the  linen,  the  same  precau- 
tions should  be  taken  as  when  injecting  with  the  short  syringe. 

I  have  learned  to  thoroughly  distrust  everything  but  nitrate  of  silver 

1  In  the  engraving  the  syringe  is  drawn  of  the  right  size ;  the  tube  is  reduced 
nearly  one -half. 


TREATMENT.  133 

for  this  purpose.  "Whatever  may  be  the  merits  of  other  injections,  I  have 
neither  seen  nor  read  anything  to  make  me  think  that  one  of  them  sur- 
passes the  nitrate  in  curative  power.  The  strength  of  the  solution  must 
depend  upon  the  sensitiveness  of  the  urethra.  When  this  is  very  marked, 
a  sixteenth  to  a  twelfth  or  an  eighth  of  the  nitrate  to  an  ounce  of  distilled 
water  will  be  quite  enough  to  begin  with,  as  the  reader  must  bear  in  mind 
that  the  solution  has  to  be  applied  over  a  much  larger  surface  than  with 
the  shoi-t  syringe.  There  is  one  safe  rule  to  guide  the  practitioner  :  he 
had  much  better  use  too  weak  an  injection  at  first  than  err  in  the  opposite 
direction,  as  it  is  always  easy  to  make  up  for  lost  time.  Much  pain  should 
on  no  account  be  caused  ;  even  when  the  patient  is  quite  indifferent  about 
such  a  result  it  is  a  gratuitous  evil  here  ;  for  injections  of  such  a  strength 
as  to  cause  great  suffering  do  not  cure  the  disease  any  quicker  than  mild 
ones,  and  they  often  make  the  urethra  so  tender  and  sore,  that  the  patient 
cannot  go  on  with  them  at  the  very  time  when  it  is  most  requisite  that  he 
should  continue  the  treatment.  Mr.  Teevan  asserts  that  they  will  bring  on 
stricture,  even  when  the  patient  has  never  had  gonorrhoea  or  gleet,  but  this 
does  not  accord  with  my  experience. 

As  to  the  quantity,  I  never  charge  the  syringe  with  more  than  a  drachm 
and  a  half  to  two  drachms  of  the  fluid,  and  of  this  quite  two-thirds  remain 
in  the  tube.  Generally  it  is  not  requisite  to  inject  more  than  every  second 
day,  and  on  no  account  more  than  once  daily.  So  soon  as  a  beginning 
is  made  with  this  instrument  the  zinc  injection  should  be  used  only  in 
great  moderation,  and  very  often  it  may  be  advantageously  given  up  alto- 
gether. 

For  the  purpose  of  injecting  the  prostatic  portion  of  the  urethra,  Dr. 
Otis  uses  a  double-bodied  tube,  one  chamber  continuous  with  that  of  the 
syringe,  and  from  which  the  fluid  is  thrown  out  by  means  of  several  fine 
openings  at  the  free  end  ;  the  other  acting  as  catheter,  and  indicating,  by 
the  passage  of  a  few  drops  of  urine,  that  the  point  of  the  instrument  has 
gone  far  enough.  So  soon  as  this  happens,  the  farther  exit  of  urine  is  cut 
off  by  means  of  a  wire  stile t,  and  the  injection  is  forced  out  of  the  openings 
a  little  in  front  of  the  neck  of  the  bladder. 

Dr.  Robert  Taylor  has  also  invented  a  very  clever  instrument  for  inject- 
ing the  posterior  part  of  the  urethra. '  It  consists  of  a  "  hard  rubber  "  tube 
about  six  inches  long,  with  an  acorn-shaped  bulb,  perforated  on  its  taper- 
ing sides  with  twelve  very  minute  holes,  arranged  in  four  rows  of  three 
holes  each.  The  apex  of  the  bulb  is  rounded,  to  avoid  injuring  the  folds 
of  the  urethral  membrane  when  it  is  introduced.  The  size  of  the  tube 
varies  from  four  to  ten,  English  bougie  scale,  and  the  widest  part  of  the 
bulb  is  two  sizes  larger  than  the  shaft.  A  button  of  hard  rubber  slides 
upon  the  shaft  to  regulate  precisely  the  spot  to  which  the  injection  is  to  be 


1  American  Journal  of  Syphilography,  etc.,  vol.  L,  p.  379. 


134:  ON    GONORRH(EA. 

applied.  The  advantages  of  this  mode  of  construction  are  that  regurgita- 
tion  is  obviated  by  the  shoulder  of  the  bulb,  that  the  smalhiess  of  the  holes 
prevents  too  much  fluid  being  thrown  in  at  one  time,  and  that  the  bulb 
serves  instead  of  a  ball-staff  to  explore  the  urethra. 

For  any  fluid  except  the  nitrate  both  plans  are  no  doubt  excellent,  but 
with  the  use  of  this  salt  begin  our  difficulties.  The  tip  of  the  syringe 
must  be  oiled  to  admit  of  its  gliding  gently  down  the  urethra,  and  the 
oil,  uniting  with  the  oxide  of  silver,  forms  a  tenacious  black  paste  very 
difficult  to  dislodge,  and  tending  constantly  to  close  even  a  tolerably  large 
orifice.  Consequently  I  have  long  given  up  this  method,  and  possess  now 
the  first  syringe  of  this  kind  which  I  had  made  many  years  ago,  and  in 
which  I  subsequently  had  the  fine  holes  plugged  and  a  large  one  made  at 
{he  apex ;  a  mode  I  decidedly  prefer. 

The  Caustic  Plug. — But  when  the  discharge  is  simply  persistent,  with- 
out there  being  any  evidence  that  the  morbid  action  has  extended  back- 
ward, then  the  application  of  the  nitrate  of  silver  for  a  prolonged  period, 
in  the  manner  now  to  be  described,  is  sometimes  beneficial.  A  slip  of  thin, 
calico,  two  inches  to  two  inches  and  a  half  long  and  a  quarter  of  an  inch 
wide,  is  first  of  all  soaked  in  solution  of  nitrate  of  silver  from  five  to  ten 
grains  to  an  ounce,  and  then  introduced  into  the  urethra  by  means  of  the 
canula  shown  in  the  drawing  on  opposite  page.  As  this  method  is  of  course 
not  often  resorted  to  until  a  gonorrhoea  has  endured  some  time,  it  will 
seldom  be  necessary  to  begin  with  a  weaker  solution  than  five  grains.  The 
surgeon  having  passed  down  the  saw-handled  stilet,  A,  and  the  canula,  B, 
sheathed  and  oiled,  withdraws  the  former,  and  then,  doubling  the  end  of 
the  linen  over  the  point  of  the  long  stilet,  c,  passes  it  steadily  through  the 
canula,  as  seen  at  D,  till  it  reaches  the  mark  =,  beyond  which  no  attempt 
should  be  made  to  push  it ;  this  done,  the  sheath  is  withdrawn  over  both. 
The  stilet  is  then  very  gently  "  wriggled  "  out,  and  the  calico  left  in  the 
urethra,  where  the  patient  is  directed  to  keep  it  as  long  as  he  can.  In 
many  of  the  cases  which  call  for  this  treatment,  it  must  be  supplemented 
by  means  which  act  on  the  more  posterior  parts  of  the  canal. 

No  fear  need  be  entertained  if,  by  any  unforeseen  movement  on  the 
part  of  the  patient,  the  calico  should  slip  into  the  urethra,  as  it  will  soon 
be  expelled.  One  day  I  was  inserting  a  plug,  the  patient  turned  suddenly, 
and  the  calico  vanished.  I  made  no  effort  to  recover  it,  and  nothing  more 
was  seen  of  it,  neither  could  I  then  or  afterward  detect  it  by  examination 
or  by  the  bougie  ;  and  as  the  patient  all  along  made  water  with  ease,  I  felt 
certain  it  had  not  remained  in  the  urethra.  A  few  days  afterward  the 
same  accident  occurred,  and  I  requested  the  patient  to  keep  watch  for  it ;  in 
two  or  three  hours  he  reappeared  with  the  plug  in  his  hand  ;  he  had  found 
it  in  his  trousers.  Indeed  I  suppose  it  always  makes  its  exodus  in  this 
manner.  I  have  known  the  same  thing  occur  several  times  when  a  tolerably 
long  piece  was  used. 


TREATMENT. 


135 


In  America  a  sponge  saturated  with  a  strong  solution  of  nitrate  of 
silver  is  occasionally  employed.  It  is  introduced  by  means  of  a  canula  for 
about  two  inches  down  the  urethra,  and  the  canula  being  partly  withdrawn, 
the  sponge  is  brought  into  contact  with  the  walls  of  the  passage,  where  it 


is  left  for  a  minute  or  two,  and  then  slowly  removed  by  twisting  it  gently 
on  its  axis.  This  plan  was  first  devised  by  Dr.  F.  Campbell  Stewart,  of 
New  York,  and  is  favorably  spoken  of  by  Dr.  Bumstead,1  who  has  em- 


1  Op.  citat  ,  p.  77. 


136  ON    GONOKRHCEA. 

ployed  it,  and  says  that  we  can  limit  the  extent  of  the  application  at  will, 
and  can  therefore  use  a  stronger  solution.  Unless  the  sponge  were 
strengthened,  I  should  have  thought  it  very  liable  to  break. 

Cauterizing  the  Urethra. — I  suppose  every  surgeon  who  has  to  treat  gon- 
orrhoea has  either  tried  caustic  to  the  urethra,  or  has  been  strongly  recom- 
mended to  do  so,  and  more  than  one  attempt  has  been  made  to  introduce 
it  as  the  remedy  for  acute  gonorrhoea  whenever  the  patient  was  resolute 
enough  to  face  it.  I  have  in  a  few  cases,  with  the  entire  concurrence  of  the 
patient,  made  trial  of  the  method  at  this  stage,  and  certainly  cannot  recom- 
mend it.  In  a  case  or  two  it  seemed  to  effect  a  rapid  cure,  but  it  failed 
more  frequently  than  it  succeeded,  and  it  was  always  abominably  painful 
if  properly  performed.  Perhaps,  however,  the  most  significant  evidence  on 
the  subject  would  be  the  desuetude  into  which  the  practice  has  fallen  among 
its  former  advocates  ;  indeed,  I  fancy  it  would  be  rather  an  awkward  question 
to  ask  some  of  them  when  they  last  employed  caustic  in  this  way.  I  know 
that  on  one  occasion,  when  at  the  house  of  a  gentleman  who  had  in  his  time 
recommended  the  nitrate,  I  requested  him  to  show  me  the  instrument  he 
used  for  applying  the  salt ;  to  the  no  small  amusement  of  both  he  at  once 
candidly  admitted,  without  any  equivocation,  that  it  was  so  long  since  he 
had  used  the  implement  in  question  that  he  didn't  know  exactly  where  to 
find  it !  He  still  contended  that  in  principle  the  treatment  was  excellent ; 
the  objection  to  it  in  practice  was  that  very  few  patients  would  allow  it  to  be 
put  into  operation,  and  that  those  who  did  so  inveighed  loudly  and  bitterly 
against  the  pain  it  set  up,  blaming  him  for  suggesting  a  measure  which  they 
themselves  had  eagerly  accepted.1 

In  the  later  stages  of  gonorrhoea  the  solid  nitrate  is  a  valuable  remedy, 
but  is  not  often  required  for  the  uncomplicated  form,  unless  the  latter  has 
become  fixed,  in  which  case  it  can  most  conveniently  be  dealt  with  as  gleet, 
under  which  head  the  reader  will  find  the  whole  procedure  described. 
When  needed  I  apply  it  for  this  purpose  by  means  of  the  instruments  de- 
scribed farther  on,2  which  are,  in  my  opinion,  superior  to  Lallemand's.  I 
had,  indeed,  to  give  up  the  latter  in  consequence  of  the  following  rather 
untoward  occurrence.  I  had  applied  the  nitrate  to  a  patient  suffering  from 
gonorrhoea,  and  on  attempting  to  withdraw  the  instrument,  found  it  was 
held  so  tightly  that  I  could  not  stir  it.  This  was  quite  a  new  state  of  mat- 
ters to  me  ;  but  at  last,  when  quite  in  despair  about  getting  it  out,  I  hit 
upon  the  idea  of  applying  scalding  hot  water  to  the  penis.  By  this  means 
I  certainly  overcame  the  spasm  and  brought  away  the  instrument ;  but  in 
the  meantime  all  the  nitrate  of  silver  had  dissolved  in  the  urethra,  and  the 
torture  the  patient  endured  was  a  lesson  I  have  not  forgotten.  Dr.  Hum- 


1  Mr.  Johnson  mentions  a  case  of  death  from  the  use  of  the  nitrate  in  this  disease. 
Op.  citat.,  p.  58. 

2 In  the  sections  on  "Strong  Tendency  to  Stricture"  and  the  "Treatment  of 
Gleet." 


TREATMENT.  137 

phrey  was  even  more  unfortunate.  In  his  case  the  instrument  broke,  and 
the  part  containing  the  caustic  was  left  in  the  patient's  prostate. ' 

It  Avould  be  wasting  the  reader's  time  to  mention  at  length  some  of  the 
remedies  (?)  which  have  been  recommended  for  acute  gonorrhoea,  such  as 
compression  of  the  urethra,  passing  a  bougie  into  the  bladder,  etc.,  etc.,  for 
the  simple  reason  that  most  of  them  cannot  be  carried  into  effect. 

Blistering  the  Penis. — If  at  the  end  of  a  week  there  were  no  change  what- 
ever for  the  better,  or  if  at  the  expiration  of  twelve  to  fourteen  days  the 
case  were  not  progressing  satisfactorily,  or  if  fixed  pain  on  the  lower  part 
of  the  penis  had  set  in,  I  would,  in  every  instance  where  the  decision  was 
left  entirely  to  myself,  proceed  to  blister  the  penis.  I  do  not,  of  course,  ex- 
pect such  a  system  will  ever  be  popular,  either  with  the  profession  or  the 
public  ;  but  I  have  no  doubt  as  to  its  value,  and  I  see  nothing  to  be  gained 
by  putting  off  measures  which  will  almost  certainly  be  required.  The 
more  too  I  see  of  gonorrhoea,  the  more  confidence  do  I  feel  in  blistering. 
The  late  Mr.  Carr  Jackson,  who  derived  his  first  impressions  of  blistering 
from  seeing  cases  which  I  had  treated  in  this  way,  carried  the  practice  quite 
as  far  as  myself  ;  he  stated  to  me  that  in  every  instance  where  there  was 
not  a  visible  improvement  by  the  end  of  a  week,  he  blistered  the  penis  if 
the  patient  would  permit  it,  a  mode  of  treatment  which,  he  said,  had  suc- 
ceeded admirably  in  his  hands.  Mr.  Chalmers  Miles  was  quite  as  enthusi- 
astic ; 2  after  a  trial  of  the  treatment  in  sixty  cases  he  formed  a  high  opinion 
of  its  efficacy.  As  most  of  his  patients  were  soldiers  who  had  been  debauch- 
ing, he  used  to  begin  by  giving  an  emetic  so  soon  as  the  patient  was  ad- 
mitted, and  on  the  evening  of  the  same  day  a  couple  of  purgative  pills,  fol- 
lowed by  an  aperient  draught  in  the  morning.  After  this  a  blister,  six 
inches  by  four,  was  placed  high  up  on  the  anterior  and  inner  part  of  each 
thigh  ;  these  were  put  on  at  night  and  left  till  morning.  They  were  made 
with  the  ordinary  cantharides  plaster,  spread  rather  thickly  on  adhesive 
plaster.  The  blistered  surface  was  afterward  dressed  with  lint  dipped  in 
castor-oil,  and  a  saline  aperient  was  ordered.  The  patient  was  put  on  spoon 
diet,  and  told  to  inject  now  and  then  a  syringeful  of  cold  or  lukewarm  water, 
according  to  the  season  of  the  year.  At  first  he  found  there  was  every  pos- 
sible variety  of  result :  generally  the  symptoms  were  aggravated,  but  this 
soon  passed  off.  On  the  third  morning  the  patient  was  usually  better.  By 
the  sixth  day  there  was  no  running,  and  on  the  seventh  day  the  man  was  dis- 
charged, fit  for  duty,  with  one  day's  convalescent  leave.  In  milder  cases  he 
blistered  the  under  surface  of  the  penis,  but  in  other  respects  treated  the 
patients  in  the  same  way.  He  had  repeated  instances  of  an  immediate  cure 
by  a  single  application.  Sometimes  the  patient  was  discharged  cured  on  the 
fourth  morning  after  admission.  When  a  relapse  happened  from  the  men 
getting  out  and  giving  way  to  a  debauch,  an  injection  or  two  of  nitrate  of 

'Holmes's  System  of  Surgery,  vol.  iv.,  p.  605.   1864. 
3  Lancet,  vol.  i.,  p.  558.    1861. 


138  ON    GONORRHOEA. 

silver  would  generally  soon  stop  it,  and  if  not,  blistering  the  thighs  was  sure 
to  succeed.  When  any  pustules  followed  the  blister  they  were  pricked, 
squeezed,  dressed  with  a  linseed  poultice,  and  then  rubbed  over  with  castor- 
oil. 

Mr.  Miles's  experience  of  the  treatment  by  blisters  was  that  it  proved 
more  speedy  and  effectual  than  any  that  he  knew  of  ;  that  it  was  suitable 
to  all  classes  of  cases  ;  that  the  period  required  to  cure  gonorrhcea  in  this 
way  ivas  from  four  to  seven  days,  though  in  some  rare  instances  it  might 
extend  to  fourteen ;  that  relapses  seldom  occurred,  and  then  only  after  a  de- 
bauch or  some  imprudence  ,  that  such  relapses  always  yielded  to  blisters  ; 
that  there  were  no  obstacles  to  the  use  of  them  ;  and  finally  that  men  em- 
ployed in  the  civil  departments  voluntarily  came  to  him  to  be  treated  in 
this  way. 

This  treatment,  which  Mr.  Miles  says  was  first  suggested  to  him  by 
Mr.  Park,  surgeon  to  the  third  brigade  at  the  Royal  Artillery  Hospital  at 
Devonport,  who  told  Mr.  Miles  that  he  had  adopted  the  plan  with  great 
success  for  a  considerable  time,  has,  he  says,  not  merely  the  advantage  of 
effecting  a  rapid  cure,  but  of  stopping,  in  a  most  summary  way,  a  trick  by 
which  soldiers  used  to  evade  punishment,  and  of  restoring  to  the  ranks  a 
great  number  of  men  who  used  formerly  to  be  on  the  sick  list.  It  is  a 
very  common  circumstance,  just  prior  to  a  garrison  field-parade,  for  the 
men  to  go  out  "  on  pass,"  and,  as  a  natural  result,  catch  an  infection. 
Prior  to  their  being  taken  before  the  commanding  officer,  they  are 
brought  to  the  surgeon  for  inspection,  and  when  found  to  be  suffering 
from  gonorrhoea  are  placed  under  treatment ;  blistering,  however,  he 
found,  soon  restored  them  to  active  service.  Again,  men  who  were  sen- 
tenced to  punishment  as  defaulters,  used  frequently  to  report  themselves 
infected  ;  in  consequence  they  were  sent  to  the  hospital,  and  thus  escaped 
punishment.  This,  too,  blistering  soon  stopped.  Furthermore,  I  know 
that  many  surgeons  have  adopted  this  method  both  in  private  and  hospital 
practice  ;  and  as  regards  the  patients  themselves,  I  should,  if  it  were  allow- 
able to  appeal  to  such  a  tribunal,  be  quite  content  to  abide  by  their  de- 
cision. 

As  what  I  said  on  the  subject  of  blistering  has  drawn  forth  some  re-* 
marks,  I  take  the  opportunity  of  placing  the  subject  in  its  true  light.  I 
never  thought  of  claiming  the  credit  of  having  discovered  that  blisters  cure 
gleet.  I  knew  that  blisters  to  the  perineum  had  been  recommended  long 
before  I  was  born  ;  nay,  even  in  Hunter's  time  they  were  used  for  this 
purpose,  as  also  to  the  under  part  of  the  urethra,1  and  Howard  confidently 
looked  forward  to  great  benefit  from  their  use  ;  but  I  believe  that,  if  other 

1  Hunter  simply  speaks  of  two  cases  of  this  treatment  having  been  mentioned  to 
him  ;  I  do  not  observe  that  he  ever  employed  it  himself  or  saw  it  employed.  Op. 
citat.,  p.  106.  Swediaur  says  that  gleets  have  been  cured  by  a  blister  to  the  parts  af- 
fected, or  to  the  perineum.  Op.  citat. ,  p.  63. 


TREATMENT.  139 

surgeons  than  those  mentioned  by  Hunter  and  Swediaur  had  ever  resorted 
to  blistering  the  penis,  the  remedy  had,  at  the  time  when  I  broached  the 
subject,  fallen  into  complete  desuetude  ;  so  much  so  that,  except  in  the 
instances  just  referred  to,  I  found  no  trace  of  the  practice  in  the  works  I 
read.  I  certainly  have  met  with  a  few  injunctions  not  to  blister  the  penis, 
which  from  their  tenor  I  should  have  said  were  written  by  those  who  knew 
nothing  of  the  matter,  but  this  may  be  a  misconstruction  on  my  part.  Of 
course,  it  is  easy  in  all  such  cases  to  rake  up  some  claim  to  priority.  The 
merit  of  treating  gonorrhoea  in  the  acute  stage  by  means  of  blistering  is 
due  to  Mr.  Chalmers  Miles.  I  have  heard  blistering  condemned  as  a  vio- 
lent remedy.  I  appeal  to  the  fact  that  many  patients,  cured  by  it  of  gon- 
orrhosa  and  gleet,  have,  on  being  a  second  time  infected,  blistered  them- 
selves of  their  own  accord. 

In  order  that  a  blister  may  be  properly  applied,  there  are  some  points 
which,  however  trivial  they  may  seem,  require  as  much  attention  as  the 
leading  features  of  the  case.  Where  these  are  neglected,  blistering  is  apt 
to  produce  such  a  filthy  mess,  that  the  patient  will  not  submit  to  it  a  second 
time  ;  whereas,  if  carefully  laid  on  and  dressed,  it  is,  from  the  part  being 
out  of  the  reach  of  friction  in  the  ordinary  movements  of  the  body,  even 
less  troublesome  than  if  on  a  limb  or  the  trunk.  Before  putting  it  on,  a 
little  of  the  hair  at  the  root  of  the  penis  is  cut  off ;  a  piece  of  paper  is  next 
fitted  on  the  penis,  and  cut  till  it  exactly  covers  it  from  the  root  to  within 
half  an  inch  of  the  mouth  of  the  urethra.  This  is  then  laid  down  on  the 
blister,  which  is  cut  out  by  it,  wrapped  round  the  penis,  and  fastened  with 
threads  behind  the  glans  and  near  the  root.  The  patient  should  remain 
quiet  while  the  blister  is  on,  lest  it  should  come  into  contact  with  the 
scrotum  and  vesicate  it,  which  is  very  soon  done.  He  should  not,  however, 
apply  it  at  bedtime,  as  he  will  most  likely  fall  asleep  and  not  awake  till  the 
penis  is  one  mass  of  vesications,  a  state  productive  of  needless  sufferings. 

In  mild  cases,  or  where  the  skin  is  very  tender,  an  hour  and  a  half  or 
two  hours  will  often  suffice  ;  the  blister  is  then  removed,  and  if  there  are 
any  vesicated  spots  they  are,  after  pricking  the  bladders  with  a  needle,  to 
be  covered  with  pieces  of  linen  or  lint  spread  with  benzoated  zinc  oint- 
ment ;  a  layer  of  cotton  wool  is  bound  over  these  and  kept  in  its  place  by 
means  of  worsted,  or  two  small  india-rubber  rings ;  or  cotton  wool  alone  is 
employed  as  a  dressing  without  any  ointment  at  all,  and  this  is  perhaps  the 
best,  as  it  is  the  simplest,  plan.  It  sticks  to  the  surface  certainly,  but  the 
adhering  part  falls  off  as  the  vesicated  skin  heals.  When  a  more  severe 
case  renders  free  blistering  necessary,  it  must  be  kept  on  three  or  four 
hours,  sometimes  longer,  but  always  till  the  penis  is  blistered.  To  protect 
the  part  from  chafing,  a  T-bandage,  with  a  linen  bag  sewed  into  the  part 
which  receives  the  penis,  or  a  handkerchief  tied  round  the  waist  and  dip- 
ping down  in  front  so  as  to  keep  it  tight  up,  will  be  found  necessary.  The 
first  effect  of  the  application  is  to  increase  the  discharge  in  some  persons, 


140  ON    GONOERHCEA. 

in  others  this  is  not  seen.  In  either  case  it  generally  soon  grows  ropy  or 
mucous,  and  finally  disappears  in  a  few  days,  or  remains  somewhat  more  per- 
sistent, requiring  a  few  injections  when  the  penis  is  so  far  advanced  toward 
healing  that  it  can  be  handled  without  pain.  It  may,  however,  demand  even 
a  second  blister.  One  of  the  most  cleanly,  convenient,  and  least  painful 
forms  of  blister  is  Brown's  cantharidine  tissue  ;  it  causes  less  irritation  than 
the  emplastrum  lyttse.  Dr.  Durkee  prefers  cantharidine  collodion  to  blis- 
ters. 

The  blistering  fluids,  if  strong  enough  to  vesicate,  caused  such  pain 
that  I  soon  renounced  the  employment  of  them  in  most  cases,  though  they 
are  very  useful  applied  to  the  perineum.  I  say  most  cases,  because  there 
are  patients  in  whom  the  skin  of  the  penis  is  so  exceptionally  tough  that 
the  blistering  tissue  will  scarcely  touch  it.  In  these  instances  they  may 
be  resorted  to.  Beyond  the  pain,  however,  I  never  had  any  untoward  re- 
sults from  the  use  of  the  vesicating  fluid  but  once.  In  the  case  I  speak  of, 
the  patient  warned  me  that  he  was  a  "  bad  subject ;"  whatever  he  had  he 
suffered  severely  from.  He  had  used  the  tissue  ineffectually,  and  I  there- 
fore prescribed  Bullin's  fluid,  enjoining  him  to  apply  it  very  gently,  instead 
of  which  he  put  in  a  most  unnecessary  quantity.  Intolerable  burning  pain 
and  swelling  of  the  organ  set  in,  and  about  a  sixth  part,  I  should  think,  of 
the  surface  of  the  penis  went  into  ulceration,  looking  like  a  bad  form  of 
multiplying  sore.  The  patient,  notwithstanding  the  free  use  of  sedatives, 
suffered  severely,  but  was  recovering  when  I  last  saw  him.  He  was  then 
on  the  eve  of  leaving  London. 

For  three  or  four  days  after  the  application  of  the  blister,  the  quieter  the 
patient  is  the  better.  So  soon,  however,  as  the  blistered  surface  begins  to 
heal  up,  a  few  mild  injections  may  be  given. 

Blistering  the  perineum  is  not  often  called  for  in  the  early  days  of 
gonorrhoea,  even  when  the  inflammation  has  extended  all  along  the  ure- 
thra ;  consequently  I  have  very  seldom  employed  it  in  such  cases,  although 
I  have  never  had,  and  should  not  have,  the  slightest  hesitation  about 
recommending  it  if  it  seemed  desirable  to  do  so.  In  gleet,  however,  it  is 
often  imperatively  demanded,  and  therefore  it  seemed  to  me  that  it  would 
conduce  to  clearness  of  arrangement  if  the  directions  for  this  process  were 
given  in  the  chapter  on  this  phase  of  the  disease,  where  accordingly  the 
reader  will  find  them. 

It  may  be  safely  laid  down  as  a  rule,  from  which  we  should  never  suffer 
ourselves  to  depart,  that  the  action  of  the  treatment  should  be  daily  gauged, 
if  I  may  so  express  myself  ;  that  is,  we  should  never  rest  satisfied  unless  daily 
progress  is  made  toward  a  cure. 

This  is  easy  enough  in  most  instances,  but  in  more  refractory  forms  of 
the  disorder  we  are  often  baffled  in  our  pursuit.  Here  we  must  look  to 
attain  our  object,  not  by  an  incessant  and  aimless  change  of  treatment, 
under  the  supposition  that  the  urethra  or  the  system  is  accustomed  to  the 


TREATMENT.  141 

remedy  ;  that  this  will  no  longer  act  upon  the  disease,  and  that  another 
will  now  have  a  greater  effect  than  if  used  at  first,  but  by  measures  express- 
ly adapted  to  the  case  in  hand.  When  really  efficacious  means  have  failed, 
we  may  generally  rest  assured  that  there  is  some  complication — some 
faulty  point  which  requires  to  be  ferreted  out,  at  whatever  expenditure  of 
time  and  trouble.  To  leave  the  disease  to  wear  itself  out — to  recommend 
change  of  air  with  this  view,  is  virtually  to  abandon  the  case  and  confess 
our  inability  to  cope  with  it. 

If  the  stomach  be  deranged  and  the  tongue  foul,  the  use  of  nitric  acid 
and  bark,  or  tincture  of  cinnamon  and  gentian  with  dilute  sulphuric  acid, 
will  often  relieve  these  symptoms  and  hasten  the  cure  ;  where  the  bowels 
or  liver  are  sluggish,  mild  doses  of  calomel,  or  blue  pill  and  rhubarb,  may 
be  used.  Mr.  Johnson  says  he  has  cured  gonorrhoea  with  sarsaparilla  and 
iodide  of  potassium  after  all  the  specifics  had  been  used  in  vain,  and  that 
in  such  cases  he  has  also  more  than  once  prescribed  with  benefit  three 
grains  of  blue  pill  and  one  of  ipecacuanha  every  night,  followed  by  an 
aperient  mixture  in  the  morning,  accompanied  or  succeeded  by  injections. 
Whatever  the  complications  may  be,  they  must  be  treated  as  if  they  oc- 
curred along  with  any  other  disease.  The  surgeon  must  use  his  own  dis- 
cretion, and  at  the  same  time  bear  in  mind  that  the  possibility  of  good 
arising  out  of  these  measures  should  not  exonerate  him  from  the  necessity 
of  at  once  taking  further  steps.  They  form  but  one  branch  of  inquiry — 
there  may  be  a  long-neglected  local  mischief. 

When  an  obstinate  case  is  brought  to  the  surgeon,  and  it  is  found  that 
no  impression  is  made  upon  it  by  this  treatment,  fairly  kept  up  for  two  or 
three  weeks ;  when  in  a  recent  case,  after  the  same  space  of  time,  the  dis- 
ease does  not  seem  to  be  giving  way ;  when,  after  putting  on  the  sem- 
blance of  a  cure,  the  disease  steadily  returns,  and  even  grows  worse  ; 
when  there  is  a  fixed  pain  on  erection, — the  urethra  should  at  once  be  sounded, 
to  ascertain  with  certainty  that  there  is  no  stricture  either  formed  or  com- 
mencing. Should  this  unfortunately  prove  to  be  the  case,  it  is  scarcely 
necessary  to  say  that  the  treatment  of  the  gonorrhoea,  at  least  so  far  as  re- 
gards injections  and  medicines,  must  be  postponed.  However,  generally 
what  cures  stricture  cures  also  the  gonorrhoea. 

When  the  case  is  complicated  with  acute  inflammation  of  any  of  the 
structures  surrounding  the  urethra,  such  as  the  cellular  tissue  around  the 
membranous  portion,  the  prostate,  etc.,  a  totally  different  treatment  is 
requisite  ;  and  the  reader  is  referred  for  further  details  to  the  chapter  on 
complications.  But  if,  on  careful  examination,  no  such  complication  can 
be  detected,  then  the  case  may  be  removed  from  the  ordinary  category  and 
considered  as  gleet,  respecting  the  special  treatment  of  which,  also,  full 
directions  will  be  given. 

Patients  naturally  think  that  when  the  discharge  has  once  ceased  they 
are  quite  safe,  and  can  do  as  they  like.  This  is  a  great  mistake.  The  run- 


142  ON    GONOKEHCEA. 

ning,  after  having  entirely  disappeared,  frequently  comes  back,  sometimes 
in  three  or  four,  sometimes  in  seven  or  eight  days.  It  has  been  observed 
to  return  at  the  expiration  of  a  month.1  This  I  have  not  seen,  but  I  feel 
assured  relapses  at  shorter  dates  are  so  frequent,  that  I  think  treatment 
ought  always  to  be  continued,  more  or  less  actively,  for  quite  eight  days  after 
the  last  drop  of  discharge  has  shown  itself. 

B.  In  the  Female. — In  the  acute  stage,  whatever  part  or  parts  may  be 
affected,  I  would  advise  precisely  the  same  internal  means  as  for  the  cor- 
responding period  of  gonorrhoea  in  the  male  ;  that  is  to  say,  preparations 
of  potass  in  almost  identical  doses,  and  the  aperient  pills  directed  to  be 
taken  along  with  them.  Delicate  women  may  require  smaller  quantities 
of  the  former,  but  I  have  never  yet,  in  these  cases,  found  the  aperient  act 
too  strongly.  The  patient  should  rest  as  much  as  possible,  and  pain, 
wherever  it  may  arise,  should  be  combated  by  means  of  opiates.  The  em- 
ployment of  these  is  never  desirable  if  it  can  be  avoided,  and  some  persons 
have  a  superstitious  dread  of  such  measures  ;  but  the  pain  is  a  greater  evil 
than  the  remedy.  At  the  beginning  the  best  injection  is,  I  think,  simple 
water,  but  even  that  should  not  be  employed  till  the  patient  can  pass  the 
tube  of  the  syringe  up  the  vagina  without  severe  pain.  A  few  days'  rest 
will  generally  secure  this  point,  and  I  have  never  seen  any  harm  arise  from 
this  brief  delay.  After  two  or  three  days'  use  of  the  warm  water,  a  very 
weak  solution  of  lead  or  zinc  may  be  thrown  up.  The  hot  hip-bath  and 
hot  fomentations  may  be  ordered,  but  the  full-length  hot  bath  as  directed 
for  men  is,  to  my  thinking,  more  efficacious  in  relieving  discomfort. 

Generally  these  rules  serve  all  useful  purposes.  If  faithfully  carried 
out,  they  often  cure  the  disease  without  anything  farther  being  done,  and 
rarely  fail  to  mitigate  the  severity  of  the  symptoms,  while  in  no  single  in- 
stance have  I  seen  any  troublesome  complications  ensue  where  they  had 
fair  play.  But  it  may  just  as  easily  as  not  happen  that  we  do  not  see  the 
patient  till  the  disease  has  become  chronic,  and  perhaps  fastened  with 
great  obstinacy  on  some  part.  I  propose  therefore  to  take  this  section  of 
the  subject  rather  more  in  detail 

In  chronic  vaginitis  the  remedy  I  prefer  to  begin  with  is  the  liquor  po- 
tassae  in  twenty  minim  to  half-drachm  doses.  It  may  be  given  twice  a  day 
in  half  a  tumbler  of  good  milk.  Should  the  appetite  be  bad,  and  the  pa- 
tient in  low  health,  as  is  often  enough  the  case,  a  full  dose  of  quinine  wine 
may  be  taken  daily  once  or  twice,  about  half  an  hour  before  a  meal  being, 
perhaps,  the  best  time ;  or  from  five  to  ten  grains  of  the  citrate  of  iron 
and  quinine,  with  just  as  many  minims  of  the  spirit  of  chloroform,  may  be 
prescribed  instead. 

The  state  of  the  bowels  should  be  strictly  looked  to.  Many  women  so 
habitually  neglect  this  function  that  it  is  surprising  they  do  not  suffer 

1  Hunter  :  Op.  citat. ,  p.  94. 


TREATMENT.  143 

more.  In  such  cases  purging  is  generally  borne  very  well  indeed,  and  the 
pills  mentioned  previously,  of  colocynth  and  hyoscyarnus,  may  be  used 
nearly  every  night.  If  the  patient  should  happen  to  be  in  a  state  of  great 
prostration,  or  liable  to  suffer  severely  from  giving  mercury  in  any  form, 
the  extract  of  chamomile  may  be  substituted  for  the  blue  pill.  And,  in  my 
opinion,  the  worse  the  patient  bears  aperients  the  more  does  she  need  them.  A 
woman,  who  suffers  severely  from  the  use  of  a  mild  pill,  has  a  much  less 
chance  of  recovering  quickly  than  a  healthier  person  ;  she  is  in  such  a  state 
of  prostration  that  tonics  alone  will  not  rouse  the  flagging  nutrition  and 
assimilation  of  the  frame.  However  puzzling  this  statement  may  appear, 
I  can  confidently  offer  it,  and  I  think  it  is  just  in  very  bad  cases  that  the 
surgeon  will  see  the  beneficial  effects  of  purgatives  in  the  most  marked 
degree. 

A  regular  crusade  should  be  begun  against  that  baneful  habit  of  stay- 
ing so  much  indoors  which  some  women  indulge  in.  Half  these  chronic 
discharges  would  never  be  heard  of  if  women  would  go  out  every  day ;  in 
fact,  it  is  out  of  the  question  that  either  mind  or  body  can  be  in  a  healthy 
state  under  a  system  of  slow  poisoning  with  bad  air. 

Injections. — In  respect  to  injections  a  much  greater  latitude  may  be 
given  than  in  men ;  for  often,  in  the  commencement,  nothing  beyond  a 
stream  of  warm  water  can  be  borne  by  some  women,  and  in  others  strong 
injections  are  soon  tolerated.  It  is  perhaps  better,  therefore,  to  begin  with 
mild  measures.  For  ordinary  cases  I  have  found  nothing  superior  to  sul- 
phate of  zinc.  Very  profuse  discharges  may  and  do  sometimes  require 
stronger  measures,  and  then  the  decoction  of  oak-bark  may  be  used  with 
the  best  effects. 

It  is  particularly  requisite  that  the  patient  should  thoroughly  under- 
stand how  to  inject  herself,  which  should  always  be  done  in  the  recum- 
bent position  with  a  pillow  under  the  hips.  A  good-sized  india-rubber 
bag,  with  two  flexible  tubes,  one  hanging  in  the  basin  holding  the  injec- 
tion, the  other,  to  introduce  up  the  vagina,  furnished  with  a  blunt  end, 
is  the  best  instrument  I  know  of.  The  vagina  should  be  thoroughly 
washed  out  previous  to  the  injection  being  thrown  up.  Sometimes  it 
answers  better  to  plug  the  vagina  with  lint  soaked  in  the  zinc  solution. 
But  in  obstinate  vaginal  gonorrhoea,  after  pain  has  ceased,  I  should  say 
the  application  of  the  nitrate  of  silver  is  the  best  remedy  yet  discovered. 
The  speculum  is  introduced,  well  oiled,  as  high  as  it  will  go,  and  then, 
all  discharge  being  first  carefully  wiped  away  by  means  of  a  piece  of  lint 
firmly  tied  to  a  stout  stilet,  a  stick  of  nitrate  of  silver  is  applied  to  the  os 
uteri,  the  speculum  is  withdrawn,  and  the  nitrate,  quickly  rotated,  is 
brought  into  contact  with  the  whole  of  the  vagina  till  the  labia  are  ap- 
proached, when  it  is  at  once  withdrawn.  Some  very  alarming  accounts 
have  been  given '  of  the  dangers  and  suffering  which  must  necessarily  arise 

1  Medical  Gazette,  vol.  xx.,  p.  310. 


144  OX    GOXORRHCEA. 

from  such  a  source,  but  they  are  refuted  on  ample  testimony  ;  men  who 
used  the  nitrate  in  numbers  of  cases,  such  as  Dr.  Egan,1  Mr.  Henry  Tay- 
lor,2 Dr.  Palethorpe,3  Mr.  Thomas  Nelson,4  and  many  others  having 
given  strong  evidence  in  favor  of  the  harmless  nature  of  the  practice. 
Pain,  however,  I  have  certainly  seen,  lasting  for  a  good  while,  after  even  a 
gentle  application  of  the  nitrate,  and  that  too,  sometimes,  in  women  whom  I 
should  not  have  thought  very  sensitive.  I  have  observed  no  other  bad 
effect,  though  I  have  applied  the  nitrate  pretty  freely  to  the  vagina  and  os 
uteri.  Dr.  Tyler  Smith  says 6  that  loss  of  uterine  substance  may  be  caused 
by  the  prolonged  use  of  the  salt  I  feel  rather  doubtful  about  the  fact, 
and  have  elsewhere  given  my  reasons  for  thinking  that  caustics  of  this 
class  do  not  destroy  sound  tissue,  and  only  act  upon  what  would  sooner  or 
later  be  removed  by  disease. 

For  a  time,  at  least,  it  seems  as  if  the  property  of  conveying  the  infec- 
tion was  extinguished  in  the  vaginal  secretion  by  the  nitrate,  most  prob- 
ably solely  by  the  chemical  action  of  the  salt.  I  certainly  have  known,  in 
a  pretty  large  number  of  cases,  that  connection  has  taken  place  after  using 
the  nitrate  while  the  vagina  was  in  a  most  unhealthy  state,  for  I  speak  of 
cases  where  I  have  applied  the  nitrate  myself,  and  yet  no  infection  has 
ensued. 

Many  years  ago  Sir  J.  Simpson  introduced  suppositories,  which  were 
inserted  into  the  vagina.6  They  were  composed  of  zinc,  lead,  etc.,  white 
wax  and  lard.  Each  weighed  about  a  quarter  of  an  ounce,  and  was  coated 
by  dipping  it  into  an  ointment  of  wax  and  resin  kept  liquid  by  heat. 
Since  then  they  have  been  introduced  more  and  more  into  practice,  and 
numerous  other  ingredients  have  been  tried.  Some  of  the  leading  Ameri- 
can physicians  make  use  of  them.  For  instance,  Dr.  John  Black,  of 
Philadelphia  Hospital,  finds T  suppositories  very  useful  in  vaginal  gonor- 
rhoea, those  containing  twelve  drops  of  the  liquor  of  persulphate  of  iron 
affecting  a  cure  in  the  shortest  time,  an  average  of  nine  days,  being  a 
remarkable  contrast  to  the  experience  of  M.  Ricord  as  to  the  time  required 
for  the  removal  of  the  complaint.  He  considers  suppositories  far  superior 
to  either  injections  or  plugging.  Dr.  Gaillard  Thomas  also  employs  sup- 
positories,8 applying  them  to  the  cervix  uteri  by  means  of  a  hard  rubber 
tube,  in  the  mouth  of  which  the  apex  of  the  cone  of  the  suppository  is 
fixed,  where  it  adheres  with  sufficient  tenacity  for  the  required  purpose. 

My  trials,  however,  with  suppositories  were  unsatisfactory,  and  I  have 
not  seen  valid  reason  for  preferring  them  to  the  nitrate,  especially  when 

1  Dublin  Quarterly  Journal,  vol.  v.,  p.  312. 

"  Medical  Gazette,  vol.  xxi.,  p.  63.  s  Ibid.,  vol.  xx.,  p.  256. 

4  Report  of  the  Committee  on  the  Venereal  Disease,  p.  113.     1868. 

6  Op   citat.,  p.  203.  *  Edinburgh  Monthly  Journal,  p.  886.     1848. 

7  American  Journal  of  the  Medical  Sciences,  vol.  1.,  p.  65. 

8  A  Practical  Treatise  on  the  Diseases  of  Women,  p.  160.     Philadelphia,  1875. 


TEEATMENT.  145 

assisted  by  the  medicines  recommended,  and  occasional  blistering,  from 
which  I  have  observed  good  results,  with  proper  diet.  Indeed  these  meas- 
ures have  generally  seemed  to  me  quite  sufficient  to  remove  vaginitis,  and 
with  the  disappearance  of  thjs,  any  affection  of  the  urethra,  if  present,  and 
of  the  mucous  membrane  of  the  vulva,  has  also  yielded  ;  nor  have  I  as  yet 
seen  the  disease,  when  thus  treated,  extend  to  the  womb  and  ovaries,  or 
to  the  bladder.  There  are,  however,  some  complications  which  may 
require  further  steps,  and  which,  unsystematically  enough  I  have  pre- 
ferred to  take  here,  so  as  not  to  break  the  thread  of  discussion,  and  to 
leave  the  ground  open  for  the  more  lengthy  examination  required  of  com- 
plications in  the  male. 

Foremost  among  these  stands  chronic  inflammation  of  the  canal  of  the 
cervix,  shown  usually  by  the  formation  of  the  stringy  plug  of  mucus  men- 
tioned in  the  first  chapter,  often  enough  accompanied  by  an  unhealthy  state 
of  the  lips  of  the  uterus.  The  plug  should  be  removed,  and  then  the  ni- 
trate may  be  gently  applied  to  as  much  of  the  surface  secreting  it  as  can 
well  be  reached.  When  the  appearances  indicate  ulceration,  or  rather  epi- 
thelial denudation,  I  believe  one  of  the  best  remedies,  certainly  that  which 
I  myself  prefer,  is  the  caustic  soda  very  lightly  applied  by  means  of  the 
speculum.  At  the  Lock  Hospital  they  first  secure  coagulation  of  the  dis- 
charge from  the  womb,  by  means  of  a  strong  astringent  like  alum,  and  then 
remove  it,  after  which  a  strong  solution  of  nitrate  of  silver  is  brushed  over 
the  cleansed  surface.  Connection  had  better  be  abstained  from,  even  when 
the  disease  seems  dying  out,  but  only  too  often  this  recommendation  is  not 
attended  to.  Rollet  says, '  that  connection  will  bring  on  relapse  after  relapse 
in  blennorrhagia  affecting  the  neck  of  the  womb,  till  even  the  parenchyma 
of  the  organ  becomes  involved. 

As  to  the  treatment  of  discharges  from  the  womb  itself,  about  the  frequent 
occurrence  of  which,  so  far  as  concerns  their  gonorrhceal  nature,  I  am  some- 
what sceptical,  I  must  at  once  say  that  I  do  not  feel  at  all  convinced  of  the 
necessity  for  the  employment  of  solid  caustics  ;  while  direct  applications, 
in  a  liquid  form,  to  the  interior  of  this  organ,  are  apt  to  be  followed  by 
nervous  symptoms  of  a  rather  alarming  nature.  I  therefore  advise  that 
treatment  should  be  confined  to  the  means  pointed  out. 

'  But  the  substance,  appendages,  and  investing  membrane  of  the  uterus 
are  liable  to  become  affected  by  a  very  serious  form  of  inflammation  from 
gonorrhoea.  Dr.  West  holds  2  that  when  acute  inflammation  is  set  up  in 
the  unimpregnated  uterus  by  gonorrhoea,  it  begins  in  the  interior  of  the 
viscus  and  extends  outward  ;  and  that,  though  it  may  involve  the  muscu- 
lar substance  of  this  organ,  it  does  so  to  a  much  less  extent  than  the  lining 
membrane.  He  considers  that  such  inflammation  should  be  attacked  en- 


1  Annales  de  Dermatologie,  tome  i.,  p.  110. 

2  Lectures  on  tlie  Diseases  of  Women,    p.  96.    1864. 
10 


146  ON    GONOERHCEA. 

ergetically,  as,  if  not,  they  naturally  pass  into  a  chronic  state,  in  which,  if 
the  patient's  danger  be  lessened,  the  chances  of  recovery  are  also  lessened. 
He  therefore  always  advises  local,  and  sometimes  also  moderate,  general 
depletion,  followed  up  by  hip-baths,  anodynes,  and  poultices  with  laudanum. 
If  pain  in  either  iliac  region,  and  still  more  if  any  distinct  swelling  in  this 
part,  point  to  involvement  of  the  ovary,  he  applies  small  blisters.  Disposi- 
tion to  pass  into  a  chronic  form  he  meets  by  a  mild  mercurial  course. 

The  treatment  advised  generaUy  for  this  group  of  cases  by  Dr.  Noegger- 
ath,  of  whose  extreme  views  I  have  already  spoken,  is  as  new  to  me  as  his 
theory,  and  consists  in  giving  quinine  to  the  extent  of  ten  to  fifteen  grains 
every  eight  hours.  When  great  pain  is  present,  and  the  disease  proceeds 
too  rapidly  to  admit  of  being  treated  with  quinine,  he  orders  tincture  of 
opium,  twenty  to  eighty  minims  at  a  dose.  If  opium  be  not  well  borne, 
we  may  prescribe  codeia,  and  apply  ice-bags  to  the  abdomen. 

Ovaritis  I  have  only  met  with  in  the  subacute  form,  and  in  all  the  cases 
I  have  seen  the  affection  had  either  begun  before  the  patient  came  under 
my  care,  or  showed  itself  within  a  short  time  after  the  first  visit ;  being 
always,  so  far  as  I  could  make  out,  due  in  some  measure  to  neglect,  over- 
work, too  much  exercise,  improper  diet,  and  so  on.  Mercury  and  opium 
in  pretty  full  doses,  hot  bathing,  rest,  and  low  diet  have  usually  proved 
sufficient,  though  in  one  or  two  cases  I  have  thought  it  as  well  to  employ 
the  chlorate  of  potass  in  addition.  Subsequently  blistering  is  often  of  ser- 
vice. 

Bicord  mentions  a  case  of  acute  ovaritis  from  this  disease,  and  de  Meric 
quotes  '  one  from  Mercier.  The  patient  was  suddenly  cut  off  by  typhoid 
fever.  Post-mortem  examination  showed  that  the  gonorrhoeal  inflamma- 
tion had  extended  to  the  uterus  and  along  the  Fallopian  tubes,  the  firnbri- 
ated  extremity  of  the  left  tube  being  destroyed,  and  the  canal  obliterated. 
Mr.  de  Meric  also  gives  three  carefully  recorded  cases  from  his  own  prac- 
tice. In  the  first  the  patient  was  a  woman,  thirty-two  years  of  age,  in- 
fected with  gonorrhoea  by  her  husband.  She  was  feverish,  and  the  pain 
was  severe  enough  to  confine  her  to  bed.  The  disorder  yielded  pretty 
quickly  to  fomentations,  a  gentle  purgative,  an  antimonial  mixture,  low 
diet,  rest,  and  counter-irritation.  In  the  second  case  the  patient  was  also 
infected  by  her  husband.  The  skin  was  hot  and  the  pulse  hard  ;  there 
was  severe  pain  in  the  left  iliac  region,  and  a  profuse  vaginal  discharge. 
Fomentations,  followed  by  large  linseed  poultices  to  the  part,  and  warm 
poppy-water  injections  into  the  vagina,  gave  relief.  Rest  and  cooling 
medicines  were  also  ordered,  and  subsequently  injections  with  counter- 
irritation  over  the  ovary  by  means  of  blisters.  In  the  third  case  there 
was  high  inflammation  of  the  vulva  and  vagina,  and  the  discharge,  which 
was  accompanied  by  considerable  hemorrhage,  was  very  profuse.  This 

1  Lancet,  vol.  i.,  p.  638.    1862. 


TKEATMENT.  147 

patient,  moreover,  suffered  from  pain  about  the  right  iliac  region,  running 
up  to  the  crest  of  the  ilium,  which  seemed  to  be  of  a  rheumatic  nature 
and  of  a  most  distressing  character.  Rest,  poppy-water  fomentations  and 
injections,  warm  hip-baths,  gentle  purgatives,  antinionials,  subsequently 
narcotic  frictions  over  the  seat  of  pain,  injections  of  alum  and  zinc,  and 
full  doses  of  opium  were  employed  ;  but  the  symptoms  yielded  very 
slowly,  a  full  month  elapsing  before  there  was  any  great  improvement ; 
whereas  in  the  first  case  the  patient  was  able  to  resume  her  household 
duties  in  about  three  weeks  ;  and  in  the  second,  although  the  discharge 
had  not  ceased  at  the  end  of  a  similar  time,  the  pain  had  yielded  pre- 
viously. 

Mr.  de  Meric  calls  attention  to  the  fact  that  in  all  these  cases  the 
ovaritis  arose  in  the  early  stage  of  gonorrhoea,  indeed  within  a  veiy  few 
days  after  it  commenced.  He  considers  that  this  circumstance,  and  the 
absence  of  any  hard  deposit  in  the  ovary,  like  that  in  the  epididymis  after 
orchitis,  militate  against  the  analogy  which  has  been  thought  to  exist  be- 
tween the  swelled  testicle  of  gonorrhoea  and  gonorrhoea!  ovaritis.  I  do 
not  think  any  weight  can  well  be  assigned  to  the  latter  ;  different  tissues 
are  in  this  respect  differently  affected  by  the  same  inflammation. 

Mr.  John  Taylor  also  communicated  two  cases  to  the  Lancet. l  In  one 
the  symptoms  were  very  severe  ;  throbbing,  agonizing  pain  extending  to  the 
back,  small  and  frequent  pulse,  hot  and  dry  skin,  loss  of  appetite,  sleep- 
lessness, and  pain  on  defecation  and  micturition.  All  this,  however, 
yielded  pretty  quickly  to  rest,  hot  fomentations,  calomel  and  opium,  and 
saline  aperients.  Dr.  Tanner,  who  was  extensively  consulted  on  such  mat- 
ters, held  that,  as  a  rule,  full  doses  of  iodide  of  potassium,  with  chlorate  of 
potass  will  be  found  more  beneficial  here  than  any  mercurial.  In  a  case 
of  gonorrhoea  affecting  a  girl  of  fifteen,  foUowed  by  endometritis,  ovarian 
congestion,  and  ovarian  neuralgia,  Dr.  E.  T.  Williams  relieved  the  latter 
symptom  with  hypodermic  injections.2 

Dr.  Tanner  says 3  it  is  doubtful  whether  ovaritis  is  due  to  disease  or  to 
its  treatment  by  astringent  injections,  copaiba,  etc.  I  do  not  wish  to  pursue 
any  writer  into  the  remote  and  fanciful  speculations  which  constitute  a 
great  deal  of  what  is  called  pathology,  but  here  the  opinion  of  this  indefat- 
igable observer  seems  to  me  tinged  with  some  want  of  reflection.  The 
action  of  copaiba,  unless  it  be  considered  plus  the  disease,  must  count  for 
nothing,  as  it  is  constantly  given  for  bronchitis  without  evoking  the  least 
trace  of  any  such  symptom  ;  united  with  the  disease  it  must  go  for  little, 
seeing  that  ovaritis  happens  where  it  has  not  been  employed.  The  same 
may  be  said  of  injections.  I  could  not  trace  ovaritis  in  a  single  case  to 
their  employment.  Two  of  the  patients  had  not  employed  them,  and  they 
do  not  seem  to  have  had  any  share  in  bringing  on  the  mischief  in  the  five 

1  Vol.  ii.,  p.  51.     1862.  J  British  Medical  Journal,  vol.  ii.,  p.  32.    1874. 

'Op.  citat.,  vol.  ii.,  p.  356. 


148  ON"   GONOKKHCEA. 

cases  of  acute  ovaritis  just  mentioned.  On  the  other  hand,  there  is  good 
reason  to  think  that  a  tendency  to  this  complication  manifests  itself  in  a 
certain  proportion  of  patients,  irrespective  of  any  treatment  whatever,  just 
as,  in  the  opposite  sex,  a  disposition  to  irritability  of  the  bladder  or  orchitis 
shows  itself,  in  a  percentage  of  cases  ;  and  that  this  tendency  is  rendered 
more  powerful  by  want  of  rest,  errors  of  diet,  and  so  on.  To  these  points, 
then,  the  attention  of  the  practitioner  may  be  beneficially  directed.  M. 
Remy,  who  by  the  way  utterly  scouts  M.  Bonniere's  anatomy  of  the  lym- 
phatics, denies1  that  the  ovary  is  ever  affected  except  through  peritonitis 
following  upon  extension  of  the  disease  along  the  Fallopian  tube  ;  a  rather 
startling  announcement  from  an  author  who  maintains  that  out  of  five 
women  who  contract  gonorrhoea  three  have  the  uterus  affected  in  this  way, 
and  that  this  organ  is  so  susceptible  of  the  disease  that  it  is  constantly  at- 
tacked when  other  parts  do  not  suffer. 

Some  of  the  French  surgeons  cauterize  the  urethra  in  the  female  when 
it  is  the  seat  of  purulent  discharge,  and  give  no  specifics  at  all.  The  results 
are  spoken  of  as  most  encouraging.  Personally  I  have  no  experience  of 
the  nitrate  here,  but  I  see  no  particular  objection  to  it  if  employed  with 
discretion.  Dr.  Bumstead  injects  the  urethra  when  the  case  is  obstinate. 

Duverney's  glands  sometimes  become  affected  in  the  course  of  this  dis- 
ease, and  it  would  really  seem  that  their  ducts  participate  in  the  extension 
of  the  gonorrhoea.  Tiedemann  was,  I  believe,  the  first  who  noticed  the 
former  of  these  facts,  having  derived  the  hint  from  Fricke  of  Hamburg.2 
Dr.  Mathews  Duncan  published,  in  the  Edinburgh  Medical  Journal,3  a  case 
of  gonorrhoea  occurring  in  a  girl  of  seventeen,  where  these  bodies  were 
involved,  being  hard  and  tender.  Pressure  upon  the  affected  part,  on  the 
right  side,  caused  about  a  drachm  of  gelatinous,  blood-stained  fluid  to 
exude.  The  disease  seemed  to  be  quickly  removed  by  bathing,  first  with 
hot  water  and  then  with  liquor  pluinbi.  These  bodies,  the  ducts  of  which 
open  on  the  inner  aspect  of  the  nymphse,  outside  the  hymen  or  carunculse 
myrtif ormes 4  are,  I  suppose,  the  bodies  described  by  M.  Huguier  as  vulvo- 
vaginal  glands,  the  orifices  of  which  open  at  this  site,  although  there  are 
exceptions  to  this,  which  sometimes  make  it  difficult  to  find  their  mouths. 
M.  Salmon  communicated,6  to  the  Academy  of  Medicine  some  cases  of 
gonorrhoea  affecting  these  ducts  ;  a  malady  pointed  out  by  M.  Huguier, 
not  easily  detected,  but  for  all  that  capable  of  conveying  infection.  It  may 
be  the  only  sign  of  disease,  and  its  existence  is  detected  by  pressing  from 
behind  forward,  in  the  direction  from  the  ischium  to  the  carunculfe.  It 
is  most  frequently  met  with  in  the  young,  and  on  the  left  side,  M.  Salmon 

1  Gazette  MeMicale,  p.  7.     1879. 

8  British  and  Foreign  Medical  Review,  VQ!.  xvi.,  p.  156 ;  Holmes's  System  of  Surgery, 
second  edition,  vol.  v.,  p.  214. 

'Vol.  xviii.,  p.  277.  4Quain's  Anatomy,  vol.  ii.,  p.  458.     1876. 

8  Union  Medicale,  tome  viii.,  p.  582. 


TREATMENT.  149 

having  found  it  there  six  times  in  eight  cases.  Injection  of  nitrate  of 
silver  with  Anel's  syringe,  and  cauterization  with  tincture  of  iodine  by 
means  of  a  fine  bougie,  or  with  solid  nitrate,  proved  useful. 

Some  women  manifest  a  tendency  to  abscess  in  the  Idbia  majora.  Like  all 
other  complications  of  the  same  kind,  the  vigorous  use  of  tartar  emetic 
and  hot  bathing,  as  recommended  in  the  treatment  of  perineal  abscess,  is, 
so  far  as  my  experience  goes,  the  only  treatment  to  be  relied  upon.  When 
once  the  abscess  points,  I  believe  authors  are  agreed  that  it  should  be 
opened,  and  that  if  allowed  to  burst  the  case  may  prove  very  obstinate.1  In 
abscess  of  the  vulva  M.  Eicord  recommends,2  that  before  it  becomes  chronic 
it  should  be  freely  opened  parallel  to  the  axis.  It  is  then  treated  by  com- 
pression, and  later  on  the  track  is  filled  with  powdered  nitrate  of  silver,  or 
a  thread  of  lint  soaked  in  acid  nitrate  of  mercury  is  passed  along  by  means 
of  a  blunt  probe.  He  effected  a  cure  in  one  very  obstinate  case  by  scarify- 
ing the  part  freely  with  the  urethrotome.3  Of  the  inflammation  of  the 
erectile  tissue  of  the  vagina  described  by  Mr.  Johnson  I  have  no  experience. 
Indeed,  he  only  saw  one  case,  and  that  proved  extremely  obstinate. 

When  excessive  menstruation  is  present,  I  believe  the  exhausting  drain 
will  almost  always  be  arrested  by  the  infusion  of  digitalis  in  drachm  doses, 
given  two  or  three  times  a  day,  with  the  same  quantity  of  syrup  of  orange 
peel  and  six  drachms  of  valerian  infusion.  The  time  for  taking  it  is  gen- 
erally restricted  to  three  days,  beginning  with  the  first  dose  on  the  second 
or  third  day  of  the  catamenial  flow. 

The  persistent  pain  in  the  back,  loins,  sacrum,  and  coccyx,  from  which 
some  women  suffer,  is  generally  relieved  by  rest,  hot  bathing,  diffusible 
stimulants,  and  strict  attention  to  the  health.  Sometimes  a  warm  belt  or 
opium  plaster  is  requisite. 

There  remain  one  or  two  points  of  treatment,  the  consideration  of  which 
I  have  reserved  till  now,  both  because  they  are  partly  local  and  partly 
general,  and  because  the  remarks  to  be  passed  upon  them  apply  to  their 
action  in  all  varieties  of  gonorrhoea.  These  points  are  the  use  of  the  cold 
hip-bath,  of  specifics,  and  of  tonics,  and  the  reader  is  to  understand  that 
what  I  have  to  say  refers  solely  to  their  power  over  the  running. 

From  the  first  of  these  I  never  saw  the  least  benefit,  while  I  have  known 
it  increase  both  pain  and  weakness.  The  process  is  exhausting,  and, 
while  conceding  everything  in  its  favor  on  the  score  of  cleanliness,  I 
think  its  action  ought  to  be  carefully  watched.  A  strong  solution  of  alum 
used  in  this  way,  has  been  recommended  ;  I  tried  it  carefully,  but  saw  no 
particular  benefit  from  its  use. 

In  opposition  to  the  opinion  of  very  good  observers,  I  believe  that 
specifics,  such  as  copaiba,  do  exert  some  influence  on  vaginal  gonorrhoea, 
as  they  do  over  most  forms  of  profuse  mucous  flux.  Those  who  contend 


1  Durkee,  op.  citat.,  p.  181.  a  Traite  Pratique,  p.  681.  3  Ibid.,  p.  682. 


150  ON    GONOEEHCEA. 

for  their  purely  local  action,  and  for  the  limitation  of  this  to  parts  over 
which  the  urine  flows,  seem  to  ignore  that  they  act  beneficially  where  no 
such  explanation  can  be  accepted,  as  for  instance  in  profuse  expectoration. 
M.  Ricord's  oft-quoted  cases  of  artificial  opening  in  the  penis,  where  the 
copaiba  only  dried  up  the  discharge  in  the  part  of  the  canal  traversed  by 
the  urine,  go  for  nothing  here,  and  the  occurrence  might,  perhaps,  be  due 
to  deficient  blood-supply  to  the  distal  part  of  the  organ.  But  I  believe 
that  the  disadvantages  of  giving  specifics  in  such  cases  outweigh  the  bene- 
fits. They  are  rarely  called  for,  and  often  fail  in  all  varieties  of  gonor- 
rhoea, except  the  urethra!,  which  will  get  well  without  them ;  while  the 
proposal  to  employ  urine  charged  with  their  specific  principles,  as  an  in- 
jection, which  has  been  more  than  once  advocated,1  is  too  revolting  in  ita 
nature  to  need  discussion. 

It  may  be  laid  down  as  a  principle  that  all  disorder  of  the  health 
should,  as  far  as  possible,  be  set  right.  Consequently  tonics  are  not  un- 
frequently  called  for,  because  many  of  these  patients  suffer  from  exhaus- 
tion and  loss  of  appetite.  Such  symptoms  they  will  often  relieve,  but  I 
believe  their  power  of  arresting  discharge  is  very  slight,  if  indeed  they 
possess  any  virtue  of  this  kind. 

Diet. — As  to  the  diet  best  suited  to  gonorrhoea  during  the  acute  stage, 
whether  in  the  male  or  female,  there  is,  I  believe,  now  but  one  opinion, 
namely,  that  it  should  be  as  light  as  possible,  and  that  beer,  wine,  and  ar- 
dent spirits  should,  as  far  as  is  practicable,  be  prohibited  ;  now  and  then 
a  little  sherry  or  claret-and-water  or  gin-and-water,  may  be  allowed  as  the 
ultima  Thule  of  indulgence.  This  refers,  however,  essentially  to  the  acute 
and  early  stage  ;  later  on  a  moderate  amount  of  wine  can  be  very  well 
added  to  the  bill  of  fare. 

But  though  a  rigorous  exclusion  of  such  articles  of  diet  as  are  only  cal- 
culated to  do  injury  may  be  justly  considered  one  of  the  most  essential 
points  of  treatment,  it  is  at  the  same  time  advisable  not  to  curb  the  patient 
in  too  strongly,  lest  he  should  turn  restive  and  break  through  all  re- 
straints ;  especially  if  he  happen  to  be  one  of  those  erratic  mortals  who 
seek  to  escape  from  such  restrictions  by  any  loophole.  The  more  simple 
and  easy  to  observe  the  directions  are,  the  more  readily  will  they  be  fol- 
lowed out,  both  in  spirit  and  letter.  Moreover,  the  greater  number  of 
cases  do  not  require  such  strict  dieting ;  and  instances  where  patients 
have  recovered  from  severe  gonorrhoea  while  actually  overstepping  all 
limits  have  tended  to  beget  a  spirit  of  scepticism,  not  only  among  them 
but  also  among  medical  men,  as  to  their  value  in  cases  which  really  require 
restriction. 

I  have  myself  no  great  faith  in  vexatious  regulations  of  any  kind  ;  I 
always  fear  they  will  prove  too  onerous  to  be  practicable.  Even  the  milcl- 

1  Union  Mcdicale,  tome  v.,  p.  112. 


TREATMENT.  151 

est  system  must  occasionally  be  relaxed,  and  now  and  then  a  good 
chop  and  a  pint  of  claret  will  do  a  weakly  man  more  good  than  any 
starving. 

The  surgeon,  then,  I  think,  will  do  wisely  in  interdicting  all  spirits 
(except  now  and  then  a  very  little  hollands  or  gin),  strong  malt  liquors, 
pork,  beef,  curries,  and  such  like — in  admitting  as  little  meat  and  wine 
as  possible,  and  in  recommending  tea,  fish,  chicken,  rabbit,  poached 
eggs,  milk  puddings,  arrowroot,  tapioca,  etc.  But  it  will  not  do  to  com- 
promise too  much  ;  and  if  the  patient  will  not  submit  to  moderate  restric- 
tion, the  blame  rests  with  him  and  not  with  the  surgeon.  The  progress 
of  science  may  one  day  reveal  to  us  some  substance  capable  of  exercising 
more  complete  control  over  inflammations  of  the  mucous  membranes, 
something  as  potent,  perhaps,  as  tartar  emetic  in  inflammations  of  the  cel- 
lular tissue  ;  then,  indeed,  we  may  free  our  patients  from  this  burdensome 
watching,  but  till  then  we  must  combat  the  disease  with  such  remedies  as 
we  possess,  and  one  of  these  certainly  is  a  moderately  low  diet. 

If  it  be  necessary  to  enforce  these  rules  at  the  commencement,  it  is 
equally  necessary  to  observe  them  to  the  end  ;  for  a  gleet  which  is  just  dy- 
ing out,  is,  so  long  as  the  microscope  shows  pus  in  the  secretion,  easily 
converted  into  a  gonorrhoea  by  a  sudden  return  to  stimulating  food,  and 
therefore  the  safest  rule  is  to  go  on  as  at  the  very  beginning  till  the  dis- 
charge has  entirely  ceased  for  some  days.  I  do  not  mean  that  the  patient 
should  starve  himself  to  the  very  last  hour,  indeed,  he  should  never  reduce 
his  strength  by  too  low  a  diet ;  but  I  do  assert  that  he  ought  not  to  in- 
dulge in  stimulants,  a  little  wine,  perhaps,  excepted,  and  not  revert  to  that 
excessive  consumption  of  meat  and  beer  which  is  so  much  the  rule  of  life 
in  England. 

As  to  the  diet  of  women  h'ttle  further  need  be  said.  I  believe  it  cannot 
be  too  light  and  plain  ;  and  as  to  the  use  of  stout,  jellies,  soup,  and  food 
of  a  similar  nature,  constantly  suggested  by  some  over-kind  friend  or 
relative,  it  cannot  be  too  strongly  deprecated.  The  persistent  use  of  what 
would  try  a  ploughman's  digestion  is  a  step  in  the  wrong  direction,  while 
of  jelly  we  may  be  permitted  to  doubt  whether  it  really  contains  any  nour- 
ishing matter  capable  of  assimilation  beyond  the  wine  used  in  making  it, 
which  is  usually  of  the  worst  kind.  Besides,  it  is  quite  a  mistake  to  think 
that  excessive  feeding  is  ever  requisite  in  such  cases. 

In  the  chapter  on  scalding  I  have  stated  my  belief  of  the  utter  useless- 
ness  of  diet  drinks,  and  their  inadequacy  to  relieve,  even  if  they  do  not  ag- 
gravate, scalding.  The  inference  to  be  drawn  from  the  arguments  there 
used  may  be  applied  here.  If  the  patient  be  very  thirsty,  the  best  diluent 
is  water. 

Smoking. — Men  often  ask  whether  smoking  is  injurious.  I  should 
have  said  that  in  moderation  it  could  not  be,  and  even  in  excess  I  have 
never  traced  any  relapse  or  aggravation  of  the  symptoms,  though  it  makes 


152  ON    GONORRHOEA. 

the  patient  low  and  nervous.  Dr.  Bumstead,  however,  thinks  '  it  is  hurt- 
ful. "I  believe,"  he  says,  "  that  either  smoking  or  chewing,  especially  in 
excess,  relaxes  the  genital  organs,  and  tends  to  keep  up  a  urethral  dis- 
charge." 

I  now  proceed  to  examine  the  complications  of  gonorrhoea.  As  some  of 
these,  when  judiciously  handled  at  any  rate,  do  not  interfere  with  the 
treatment  of  the  parent  disease,  while  others  must  be  overcome  before  we 
can  hope  to  effect  a  cure,  I  thought  it  would  be  best,  in  a  work  devoted  in 
great  part  to  therapeutics,  to  adopt  a  purely  arbitrary  classification,  and 
separate  these  symptoms  into  two  groups ;  one  comprising  those  which 
may  be  taken  in  hand  at  the  same  time,  that  is  to  say,  complications  which 
do  not  interfere  with  treatment ;  and  another  containing  those  which  at  an 
early  period  acquire  such  an  importance  as  to  require  the  particular  atten- 
tion of  the  surgeon,  and  which,  in  consequence,  really  do  interfere  with 
treatment.  Such  an  arrangement  is,  I  at  once  admit,  highly  unscientific, 
but  I  know  of  no  better. 

'Op.  citat.,  p.  83. 


CHAPTER  Y. 

TREATMENT— (CONTINUED). 

COMPLICATIONS  WHICH  DO  NOT  INTERFERE  WITH  THE  CURE  OF  GONORRHOEA. — 
1.  SCALDING  :  Pathology. — As  it  is  inost  desirable  that  all  statements  made 
here  should  rest  on  the  broadest  possible  basis,  I  shall  first  of  all  proceed 
to  examine  what  light  organic  chemistry  throws  upon  this  part  of  the  sub- 
ject. One  chemist  tells  us  that  "we  can,  by  a  judicious  choice  of  food, 
bring  the  urine  into  any  state  that  can  be  wished  for."  Mr.  Durham 
pretty  nearly  endorses  this.  He  says  '  it  is  easy  to  deprive  the  urine  of  its 
irritating  acidity  "  by  proper  regulation  of  the  diet  and  the  free  use  of 
alkaline  medicines."  This  view  must,  I  submit,  be  accepted  with  some 
reservation,  for  the  influence  of  these  means,  though  considerable  at  times, 
is  not  unfailing. 

The  first  point  inquired  into  in  my  observations  was,  whether  scalding 
depends  upon  the  presence  of  any  particular  ingredient  in  the  urine,  de- 
rived from  the  gonorrhoea,  because  if  any  such  could  be  detected  some  rem- 
edy might  be  found ;  but  this  I  could  not  learn.  However,  I  may  have  over- 
looked the  right  source,  as  organic  chemistry  is  acquiring  such  dimen- 
sions that,  at  no  very  distant  date,  it  will  require  a  lifetime  to  master  the 
works  pertaining  to  the  subject.  Within  the  last  twenty  years  alone  the 
contributions  have  been  so  vast,  that  any  person  who  is  not  a  pure  chemist 
and  nothing  else,  finds  himself,  when  once  entangled  in  'such  a  compli- 
cated matter,  in  the  dilemma  of  a  traveller  who  has  fairly  lost  his  way  in 
some  trackless  waste. 

However,  I  will  try  to  make  the  best  of  the  difficulty,  and  begin  by  giving 
the  only  specific  information  I  have  been  able  to  meet  with.  It  is  taken 
from  the  carefully  prepared  work  of  M.  Alfred  Becquerel,"  who  says, 
"The  existence  of  a  simple  blennorrhagia,  whether  acute  or  chronic,  only 
produces  in  the  urine  a  small  quantity  of  muco-pus,  rarely  enough  in 
quantity  to  render  the  urine  alkaline.  When  the  running  is  very  great,  it 
sometimes  happens  that  the  urine  passed  in  the  morning,  on  rising,  con- 
tains more  muco-pus  than  that  passed  at  other  periods  of  the  day,  that 
there  is  little  albumen  in  it,  and  that  it  is  less  acid  than  usual."  As  this 

1  Guy's  Hospital  Reports,  third  series,  vol.  xv. ,  p.  470. 

2  Semeiotique  des  Urines,  p.  475.     1841. 


154  ON    GONORRHCEA. 

statement  throws  little  light  on  the  special  subject  of  research,  let  us  take 
the  general  state  of  the  urine,  and  examine  if  any  of  its  component  parts 
will  offer  a  clue  to  the  enigma. 

Dr.  Golding  Bird  considers '  it  probable  that  the  uric  acid,  just  as  it  is 
separated  from  the  blood,  comes  in  contact  with  the  double  phosphate  of 
soda  and  ammonia,  evolving  phosphoric  acid,  which  thus  produces  the  nat- 
ural acid  reactions  of  urine;  and  Sir  Thomas  Watson  says:2  "Modern 
chemistry  teaches  that  the  acid  reaction  of  healthy  urine  is  due  to  the 
acid  phosphate  of  soda."  This  view  is  endorsed  and  enlarged  by  Dr.  Har- 
ley,  who  thinks3  that  "the  acidity  of  urine  depends  on  the  united  pres- 
ence of  acid  phosphate  of  soda,  uric  (hippuric)  and  lactic  acids."  Accord- 
ing to  Dr.  Hassall,4  "  The  acidity  of  the  urine  is  principally  due  to  the 
presence  of  acid  phosphates ;  but  in  some  cases,  lactic  and  carbonic  acids 
contribute  to  the  acidity."  Dr.  Beale  holds  that,5  "The  cause  of  the  acid 
reaction  of  urine  is  obscure,  and  probably  does  not  always  depend  upon 
the  presence  of  the  same  substance.  Sometimes  the  reaction  may  depend 
upon  carbonic  acid,  which  is  present  in  greater  or  less  proportion  in  all 
the  animal  fluids."  ....  "  A  fixed  acid  reaction  may  be  due  to  the 
presence  of  the  acid  phosphate  of  soda — a  salt  which  exhibits  an  acid  re- 
action without  the  presence  of  any  free  acid."  He  admits,  however,  that 
traces  of  free  organic  acids  are  found,  and  it  is  pretty  certain,  from  what 
follows,  that  these  acids  are  the  lactic  and  hippuric.  According  to  Dr. 
Roberts,0  "  healthy  urine  is  generally  acid.  This  arises  chiefly  from  the 
presence  of  a  number  of  acid  salts — phosphates  and  urates ;  partly  also 
from  free  acids — lactic,  oxalic  acids,  etc." 

Most  likely  then,  so  far  as  the  scalding  depends  on  the  composition  of 
the  urine,  its  origin  must  be  traced  to  the  action  of  these  causes  of  acidity, 
and  its  remedy  be  sought  for  in  agents  which  counteract  them.  Uric  acid, 
especially  if  in  excess,  may  play  some  part  here,  as  superabundance  of  it  in 
the  urine  is  sometimes  accompanied  by  scalding.  Sir  Benjamin  Brodie 
has  not  hesitated  to  say  7  that,  combined  with  ammonia,  it  is  the  cause  of 
acidity.  Assuming,  now,  that  the  balance  of  power  is  to  be  divided  be- 
tween it  and  the  acid  phosphate  of  soda,  I  suppose  it  must  be  accepted 
that  organic  chemistry  does  not  show  us  how  we  are  to  prevent  their  ap- 
pearance. Harley  says 8  that  the  amount  of  uric  acid  in  the  urine  is 
materially  lessened  by  a  vegetable  diet,  but  it  will  show  itself  even  when 
no  food  is  taken.  Lassaigne  detected  it  in  the  urine  of  a  maniac  who  had 
fasted  fourteen  days,  and  Wagner  observed  that  it  was  found  in  larger 

1  On  Urinary  Deposits,  p.  95.    1857.  9  Op.  citat.,  vol.  ii. ,  p.  637. 

8  The  Urine  and  its  Derangements,  p.  10.  1872. 
*  The  Urine  in  Health  and  Disease,  p.  23.  1859. 
•Kidney  Diseases,  etc.,  p.  118.  1869. 

6  On  Urinary  and  Renal  Diseases,  p.  48.     1876. 

7  Works,  vol.  ii.,  p.  539.  8  Op.  citat.,  p.  65. 


TREATMENT.  155 

quantity  after  fasting  than  when  vegetable  diet,  or  food  freed  from  nitro- 
genous matter  (?)  was  used.  A  similar  statement  has  been  made  by  Prout1 
with  respect  to  its  ammonia  compound.  Port  wine  and  beer  are  said  to 
increase  the  elimination  of  uric  acid  ;  tea  and  coffee  to  diminish  it,  and  I 
may  remark,  as  a  fact  to  be  afterward  weighed,  that  I  have  several  times 
had  good  reason  to  believe  coffee  aggravated  the  scalding.  The  action  of 
medicines  is  also  here  somewhat  opposed  to  experience.  Phosphate  of 
soda,  liquor  and  bicarbonate  of  potass,  increase  the  elimination  of  uric 
acid  from  the  system ;  while  acetate  of  potass,  quinine,  cod-liver  oil  and 
colchicum  lessen  the  amount.  Yet  practical  men  profess  to  have  seen 
relief  of  the  scalding  from  the  use  of  both  liquor  potassse  and  bicarbonate 
of  potass  ;  and,  as  I  have  just  said,  this  symptom  will  come  on  while  the 
patient  is  under  the  influence  of  the  acetate. 

We  become  involved  in  a  similar  contradiction  with  respect  to  hippuric 
acid,  which,  according  to  Harley,  possibly  contributes  in  a  great  measure 
to  the  acidity  of  normal  urine,  and  this  author  informs  us  that  the  largest 
amount  of  hippuric  acid  passed  in  the  twenty-four  hours  is  found  to  follow 
a  purely  vegetable  diet ;  while  Dr.  Hassall  says  that  "  its  presence,  inmost 
cases,  is  obviously  connected  with  the  free  use  of  vegetable  or  other  sub- 
stances rich  in  carbon,  as  milk."  Setting  this  against  the  action  of  differ- 
ent kinds  of  food  on  uric  acid,  the  conclusion  we  must  come  to  is,  that 
what  we  do  with  one  hand  we  to  a  great  extent  undo  with  the  other ;  and 
I  am  not  aware  that  there  is  any  remedy,  in  the  shape  of  medicine,  which 
controls  the  elimination  of  hippuric  acid.  It  may  be  remarked,  too,  that 
a  light  diet,  in  which  milk  usually  plays  a  great  part,  contributes  to  the 
relief  and  prevention  of  scalding. 

The  lactic  acid  of  the  urine  cannot,  I  think,  be  accepted  as  a  factor, 
except  in  so  far  as  it  contributes  its  quota  ;  that  is  to  say,  I  believe  it  has 
never  been  shown  that  undue  excess  of  it  causes  greater  acidity  than 
usual,  and  it  is  with  this  part  of  the  matter  alone  that  we  have  to  deal. 
The  other  constituents  of  the  urine,  the  acids  which  still  remain,  the  salts, 
urea,  uro-hrematin,  need  not  detain  us,  as  there  does  not  appear  to  be  any 
evidence  that,  individually  or  combined,  they  exert,  or  are  calculated  to 
exert,  any  influence  on  the  symptom  in  question. 

I  must  now  ask  the  reader's  particular  attention  for  one  point  in  this 
question.  Some  years  ago,  Dr.  Bence  Jones  asserted  that  urine  lessens  in 
acidity,  and  even  becomes  alkaline  in  some  cases,  for  two  or  three  hours 
after  breakfast  and  dinner.  Roberts,  Harley  and  Beale  have  all  discussed 
this  statement.  The  first  named  author  supports  it  in  the  most  unqualified 
manner.  Dr.  Harley  says  he  has  been  unable  to  verify  it  in  perfectly 
healthy  persons,  but  sees  nothing  improbable  in  it,  "  if  the  person  experi- 
mented on  has  partaken  largely  of  vegetable  food  ; "  certainly  an  unusual 

1  On  Urinary  Diseases,  p.  81.     1840. 


156  ON    GONORRHCEA. 

condition,  in  the  shape  of  excess,  with  respect  to  breakfast.  Dr.  BeaJe 
says  that  Beneke  made  upward  of  a  hundred  observations  without  being 
able  to  confirm  Dr.  Jones's  statement  In  only  one  case  did  he  find  the 
urine  alkaline.  Sometimes  the  acidity  was  lessened,  but  this  was  not  in- 
variably the  case.  He  found  that  the  acidity  of  the  whole  amount  of 
urine  passed  varied  considerably,  but  could  not  discover  the  cause.  "It 
seemed  to  be  independent  of  the  quantity  passed  and  was  not  affected  by 
exercise  or  food."  With  such  discrepancy  among  very  able  observers  and 
on  so  simple  a  thing  too,  we  may  well  pause  before  we  accept  sweeping  as- 
sertions about  the  control  of  food  over  the  reaction  of  the  urine,  or  give 
up  the  lessons  of  experience  in  favor  of  those  issuing  from  the  laboratory. 
It  will  not  be  necessary,  for  the  sake  of  the  system,  to  say  anything  about 
prognosis  or  results. 

Treatment. — Remedies  usually  recommended, — After  carefully  reading 
every  work  and  paper  to  which  I  could  obtain  access,  I  have  not  been  able 
to  obtain  any  information  as  to  the  best  method  of  treating  this  and  some 
other  symptoms,  which  proved,  when  reduced  to  practice,  of  value.  Nu- 
merous remedies,  it  is  true,  are  indicated,  but  their  effects  did  not  quite 
correspond  with  the  expectations  which  the  accounts  of  them  were  cal- 
culated to  raise.  In  order,  therefore,  to  ascertain,  as  far  as  I  could,  their 
precise  action,  I  first  of  all  divided  them  into  the  four  following  classes  : — 
1.  Anodynes — as  laudanum,  morphia,  belladonna,  etc. ;  2.  Demulcents — 
as  linseed-tea,  barley-water,  gum  arabic  ;  3.  Diuretics — as  nitrate  of  potass, 
sweet  spirit  of  nitre  ;  4.  Alkaline  remedies — as  soda,  potass,  and  magnesia. 

With  a  view  of  avoiding  every  source  of  fallacy,  these  four  classes  were 
tried  successively  on  a  great  number  of  patients  ;  every  symptom  connected 
with  the  advance  or  decline  of  the  scalding  in  each  particular  case  was 
registered  in  the  blank  forms  already  spoken  of  ;  and  the  patients  were  for 
the  most  part  examined  every  morning.  At  the  same  time  nothing  was 
omitted  that  seemed  likely  to  hasten  the  cure,  so  that,  as  far  as  they  go, 
the  results  obtained  may  be  fairly  viewed  as  a  summing  up  of  the  action  of 
these  remedies  on  the  symptom  in  question.  The  results  were  as  follows : — 

1.  Anodynes. — The  effects  of  these  were  most  unsatisfactory.  They 
were  used  in  the  form  of 

Laudanum. — In  some  cases,  where  there  was  severe  pain  from  other 
causes,  this  remedy  was  pushed  to  the  extent  of  a  hundred  drops  in  a  day, 
yet  even  in  such  large  quantities  it  only  produced  temporary  relief  of  the 
scalding  ;  and  in  doses  of  this  magnitude,  even  if  it  removed  the  symptom 
it  was  given  for,  the  constipation  and  headache  it  brings  on  sooner  or  later 
would  be  sufficient  objections  to  its  use.  Morphia  in  small  doses  was  in- 
efficient, and  in  large  quantities  objectionable,  for  the  same  reasons  as 
opium.  Dover's  powder  yielded  the  same  results. 

Hyoscyamus  alone,  or  combined  with  salines,  appeared  in  some  cases  to 
hasten  the  disappearance  of  scalding  when  injections  were  used  ;  but  on 


TREATMENT.  157 

trying  it  singly  it  was  found  to  produce  no  effect,  so  that  the  first  impres- 
sion must  have  been  illusory.  Applied  externally  it  had  no  very  marked 
action,  and  made  a  filthy  mess — an  inconvenience  to  which  patients  suffer- 
ing under  these  complaints  object  most  seriously.  Veratrin  and  atropin 
applied  in  ointment  produced  torpor  of  the  part,  but  no  permanent  relief  of 
the  scalding.  Of  the  alkaline  sedatives,  such  as  bromide  of  potassium, 
highly  praised  for  this  purpose  by  some  writers,1  I  have  little  experience, 
and  that  little  is  not  favorable. 

2.  Demulcents  exerted  but  very  slight  effect,  though  the  patients,  in 
some  instances,  drank  as  much  as  a  quart  of  thick  linseed-tea  in  a  day. 
These  remedies  have  been  recommended  by  many  writers,  although  not 
one  of  them  seems  to  have  ever  examined  their  properties  in  such  a  man- 
ner as  can  alone  justify  a  man  in  speaking  positively  about  a  point  of  this 
kind.     From  numerous  observations,  I  am  disposed  to  doubt  whether  they 
possess  any  of  the  virtues  attributed  to  them,  and  whether  they  are  not 
simply  a  relic  of  the  old  drenching  system — a  waste  of  time,  labor,  and 
patience  ;  water,  especially  if  pure,  will,  I  believe,  effect  the  same  purpose 
much  more  cheaply  and  conveniently.    They  may  possess  a  certain  amount 
of  negative  value,  e.g.,  when  a  patient  will  not  drink  water,  and  the  medi- 
cal attendant  finds  himself  compelled  to  order  something,  then  he  may 
direct  barley-water,  because  it  is  less  heating  than  coffee  or  any  kind  of 
wine,  etc.,  but  active  beneficial  power  I  do  not  believe  them  to  be  endowed 
with.     Yet,  to  judge  from  what  some  writers  say,  it  would  seem  that  the 
most  certain  and  pleasant  mode  of  curing  gonorrhoea,  and  averting  such 
results  as  stricture,  is  to  give  plenty  of  demulcents  internally. 

As  to  the  old  explanation  that  they  sheath  the  inflamed  mucous  mem- 
brane and  thus  prevent  the  acridity  of  the  urine  from  acting  on  it,  or  en- 
velop the  urine  itself  (!),  it  sounds  very  like  Cullen's  wonderful  theory  of 
the  acrimonious  spiculae  in  tabes  venenata  being  sheathed  by  the  oil 
absorbed,  for  this  express  purpose,  from  the  cells  of  the  cellular  membrane 
into  the  blood.  Perhaps  the  reader  will  say,  why  pursue  with  arguments 
an  old  doctrine  which  has  well  nigh  died  out  of  itself  ?  But  the  truth  is 
that  it  is  anything  but  in  a  moribund  state,  and  that  it  is  virtually  upheld 
by  every  man  who  asks  us  to  believe  that  the  mucilage,  whether  of  the 
acacia  tree  or  flax  plant,  passes  unchanged  through  the  capillaries  of  the 
stomach  and  the  epithelial  structure  of  the  kidneys,  which  it  must  do  to 
justify  prescribing  it  in  scalding. 

3.  Diuretics  seemed  to  have  some  slight  effect,  and   the  solution  of 
nitrate  of  potass  in  barley-water,  half  an  ounce  to  a  pint,  appeared  to  relieve 
the  scalding  in  many  cases,  just  as  spirit  of  nitre,  gin-and- water,  and  tea  do, 
namely,  by  producing  an  increased  secretion  of  water  from  the  kidneys. 
It  displayed  no  power  of  materially  benefiting  this  symptom  so  long  as  the 

'Practitioner,  vol.  ii.,  p.  101.   1874. 


158  ON   GONORRHOEA. 

diseased  state  of  the  urinary  passage  remained  unabated.  These  remedies, 
however,  are  perhaps  the  most  efficacious  that  have  as  yet  been  tried,  and 
are  perfectly  harmless  in  anything  like  moderation. 

4.  Alkalies, — Of  these,  the  carbonates  of  soda,  potass,  and  magnesia,  and 
the  liquor  potassce  were  tried,  both  alone  and  combined  with  some  of  the 
other  remedies.  I  was  induced  to  use  these  from  almost  always  finding 
the  urine  acid  in  gonorrhoea,  especially  as  I  had  been  repeatedly  told  that 
they  were  the  best  remedies  for  this  symptom  ;  and  I  was  naturally  enough 
rather  anxious  to  find  in  some  of  these  medicines  a  remedy  against  a 
symptom  of  which  patients  complain  a  good  deal,  and  which,  if  not  very 
important,  is  annoying ;  but  the  attempt  was  as  unsuccessful  as  those 
made  with  the  demulcents  and  sedatives.  The  following  results  were  ob- 
tained from  the  observations  made  respecting  their  action  : — 

1.  The  urine  became  alkaline  in  some  cases,  but  the  acidity  returned 
even  when  the  alkaline  remedies  were  continued. 

2.  This  change  was  not  accompanied  by  a  relative  change  in  the  scald- 
ing. 

3.  This  change  ensued  in  some  cases  where  no  antacid  remedies  were 
used. 

4.  The  scalding  was  relieved  without  the  acidity  of  the  urine  being 
affected. 

5.  When  the  patients  were  seen  but.  once  a  week,  these  remedies  were 
used  during  periods  varying  from  two  or  three  weeks  to  as  many  months, 
without  in  some  cases  relieving  the  scalding,  which,  however,  began  to 
disappear  so  soon  as  the  condition  of  the  urethra  improved. 

6.  In  some  cases,  in  the  latter  part  of  the  acute  stage,  alkalies  were  of 
service  when  combined  with  other  means,  such  as  injections ;  but  of  less 
value  in  the  early  part  of  this  stage,  in  which  diuretics  gave  more  relief. 

7.  In  the  scalding  which  sometimes  very  suddenly  attacks  those  recov- 
ering from  gonorrhoea,  alkalies  were  often  productive  of  positive  harm,  and 
tended  to  exasperate  it. 

8.  Again,  though  the  urine  was  acid  in  this  stage  (the  ,decline).  nitric 
acid  was  apparently  often  productive  of  relief.     I  say  apparently,  because 
this  scalding  will  sometimes  come  and  go  in  forty-eight  hours  ;  and  therefore 
it  is  extremely  difficult  to  say  what  it  is  that  carries  it  off. 

9.  That  scalding  will  sometimes  occur  in   patients  who   have  been 
treated,  all  along,  with  the  preparation  of  potass  which  I  have  recommended 
for  gonorrhoea. 

10.  That  the  presence  of  scalding  need  not  delay  the  cure  of  gonorrhoea 
for  an  hour,  and  that  its  removal  does  not  in  any  way  promote  or  retard 
the  influence  of  treatment,  the  question  being  one  which  simply  affects  the 
comfort  of  the  patient 

After  stating  the  results  of  my  own  observations,  I  think  it  only  just  to 
say  that  the  late  Mr.  "VVeeden  Cooke  came  to  very  different  conclusions. 


TREATMENT.  159 

He  tells  us  l  that  scalding  is  the  result  of  the  acid  urine  passing  over  the 
highly  inflamed  surface  of  the  urethra,  and  that  this  symptom  should  be 
remedied  by  the  administration  of  alkaline  carbonates,  with  the  view  of 
neutralizing  the  acidity  of  the  urine,  and  thus  removing  the  principal  cause 
of  the  continuance  of  the  inflammation. 

It  is  often  very  difficult  to  make  the  urine  alkaline,  though  this  may  be 
accomplished  by  overwhelming  doses  of  alkalies.  Thus  Wagner 2  found 
that  two  drachms  of  carbonate  of  soda  rendered  it  alkaline  in  three-quar- 
ters of  an  hour,  which,  however,  could  be  only  a  transient  state  unless  the 
action  were  maintained  by  fresh  supplies.  Indeed,  the  alkaline  reaction  in 
this  case  only  lasted  three  days,  while  two  drachms  of  acetate  of  potass 
only  made  the  urine  alkaline  for  sixteen  hours.  According  to  my  own  ob- 
servations, neither  small  nor  large  doses  effect  this  change  in  many  cases 
so  readily  and  easily  as  might  have  been  expected.  Sir  Henry  Thompson 
says,3  "  By  giving  alkalies  you  can  make  the  urine  neutral  or  alkaline  to 
any  extent  you  please."  In  that  case  either  my  observations  or  his  must 
be  at  fault.  The  following  short  cases  will,  I  hope,  tend  to  substantiate  all 
I  have  stated. 

Thomas  E, took  §  j.  of  sulph.  of  soda  daily  in  barley-water.  The 

first  morning  the  urine  was  acid,  the  scalding  gone ;  but,  on  careful 
examination,'  it  was  found  to  have  been  nearly  gone  the  day  preceding,  and 

it  returned  again.  Thomas  J took  f  j.  of  sulph.  of  soda.  Sixteen 

hours  after  the  urine  was  found  alkaline,  the  scalding  had  gone  ;  its  dis- 
appearance was  traced  to  the  use  of  a  warm  bath.  The  day  after  this  it 

had  returned,  and  a  warm  bath  again  relieved  it.  George  P •  took 

3  j.  of  carb.  of  soda  and  §  j.  of  phosphate  of  soda  in  barley-water.  He 
did  not  experience  much  benefit,  the  scalding  having,  in  fact,  gone  from 
taking  a  warm  bath.  Eighteen  hours  after  the  urine  was  acid,  and,  on 
standing,  deposited  a  thick  flour-like  sediment ;  the  scalding  returned. 

Charles  H took  §  j.  of  the  phosphate  of  soda  in  barley-water.  Next 

morning  the  scalding  was  worse  ;  the  urine  not  examined.  George  T 

took  3  j.  of  nitrate  of  potass  and  3  ss.  of  pulv.  ipecac,  c.  in  barley-water. 
Next  day  the  urine  was  neutral,  and  the  scalding  not  so  severe  ;  he  re- 
peated the  dose,  and  the  day  after  the  urine  was  strongly  acid,  and  the 

scalding  as  severe  as  ever.  Henry  B had  had  scalding  for  fourteen 

days.  By  taking  3  ivss.  of  nitrate  of  potass  and  3  iss.  of  pulv.  antim.,  in 
eight  days  he  was  relieved,  the  disease  having  given  way  at  the  same  time. 

James  B took,  in  thirty -one  days,  §  iss.  of  carb.  of  soda  and  f  j.  of 

pulv.  jalap,  in  small  doses  three  times  a  day ;  the  scalding  gradually 
diminished,  the  disease  going  at  the  same  time.  During  the  first  fourteen 


1  Lancet,  vol.  i.,  p.  90.     1860. 

a  Handworterbuch  def  Physiologic,  B.  ii.,  Art.  Ham.     184&-49. 

8  Diseases  of  the  Urinary  Organs,  p.  200.     1873. 


160  ON    GONOKRHCEA. 

days  he  had  no  diminution  of  the  scalding.     Thomas  K ,  took  3  j.  of 

nitrafe  of  potass  and  gr.  xxiv.  of  pulv.  antim.  in  six  days.  The  scalding, 
which  was  going  away,  diminished  under  the  use  of  this  remedy.  Henry 

H had  acid  urine  and  scalding.     To  take  liquor  potassge  3  ss.  ter  die. 

Four  days  after  the  urine  was  acid  ;  scalding  still  continued.  To  take  the 
dilute  nitric  acid  in  decotft.  of  pareira  brava.  Ten  days  after  this  the 

scalding  was   gone,  the  urine   still  acid.     Samuel   E ,   while  taking 

liquor  potass.,  was  suddenly  attacked  by  scalding  ;  urine  acid,  sp.  gr. 

1028.     J.  H.  "W had  scalding  from  gonorrhoea.     To  take  a  scruple  of 

nitrate  of  potass  and  3  ss.  of  gum  Arabic  thrice  a  day,  with  Dover's  pow- 
der every  night,  and  injections  thrice  a  day.  Four  days  later  the  scalding 

was  much  relieved,  and  in  a  few  days  disappeared.     Thomas  E had 

had  scalding  from  gonorrhoea  two  months.  To  take  carbonate  of  soda, 
gr.  viij.,  and  opium  gr.  £  twice  a  day.  Two  days  after  he  reported  that 
the  bowels  were  confined  ;  scalding  much  the  same.  Garb,  of  soda,  gr. 
xij.  and  pulv.  jalap,  gr.  xij.  twice  a  day  ;  injection  three  times  a  day.  Six 
days  after  this  was  reported  relieved  ;  to  go  on.  Again  two  days  later  the 
scalding  had  disappeared.  Here  the  alkali  was  clearly  of  some  use, 
as  he  had  been  using  the  same  injection  for  two  months,  with  mild 
aperients. 

Two  patients,  with  a  slight  discharge  of  long  standing  and  some  scaldt 
ing,  were  put,  one  on  the  soda  and  opium  powder,  the  other  on  the  soda 
and  jalap.  At  the  end  of  nine  days  they  were  examined  again,  having  in 
that  time  taken  each  f  ss.  of  the  alkali.  The  patient  who  had  taken  opium 
and  soda  had  lost  the  scalding,  and  with  it  the  discharge.  In  the  other, 
who  had,  however,  taken  some  beer,  it  continued  unabated.  Charles 

C had  had  scalding  from  gonorrhoea  in  a  very  severe  form  for  some 

days.  He  was  ordered  a  mild  saline  purgative,  his  bowels  being  confined, 
and  to  be  injected  three  times  a  day.  The  scalding  disappeared  in  a  few 
days,  and  did  not  return.  G.  W had  very  severe  scalding  from  gonor- 
rhoea. He  took  one  drachm  of  soda  in  water,  and  was  injected.  When 
seen  the  following  morning  the  scalding  had  diminished,  and  the  urine 
was  alkaline.  On  the  evening  of  the  same  day  he  took  a  drachm  of  the 
carbonate  and  was  again  injected.  One  day  later  the  urine  was  reported 

acid ;   the   scalding  had  diminished.     Joseph   M had   scalding,    for 

which  he  was  ordered  a  combination  of  soda  with  jalap  powder.  After 
thirty-five  days'  continuance  of  this,  in  the  course  of  which  time  he  had 
taken  four  ounces  and  a  half  of  carbonate  of  soda,  the  scalding  was  still 

present,  though  slight.     Charles  L had  been  for  some  days  using 

nitrate  of  potass  for  gonorrhoea  and  scalding.  To  take  carbonate  of  soda, 
ten  grains  three  times  a  day.  He  was  also  injected.  Three  days  after 
the  scalding  was  better,  the  urine  natural.  To  go  on.  Two  days  after 
this  the  scalding  lessened,  the  urine  neutral.  To  continue  the  alkali  and 
injection.  The  next  day,  urine  acid,  the  scalding  giving  way  ;  the  dis- 


TREATMENT.  161 

charge  diminished  to  a  gleet.  Inject  again  and  continue  the  soda.  The 
day  after  it  was  found  that  he  had  caught  a  cold ;  the  scalding  had  re- 
turned as  bad  as  ever. 

I  could  fill  pages  with  such  notes,  but  it  seems  needless  to  pursue  the 
point  farther.  It  appears  to  me  that  enough  has  been  said  to  show  that 
none  of  these  substances  can  really  be  depended  on  for  the  removal  of  the 
scalding.  I  will  only  stop  to  add  that  benzoic  acid  was  tried,  with  a  view 
of  converting  the  uric  into  hippuric  acid,  and  that,  like  the  rest,  it  had 
no  material  effect.  In  all  these  cases  the  urine  selected  for  examination 
was  either  that  passed  on  rising,  or  the  first  voided  after  breakfast ;  most 
usually  the  latter. 

It  was  while  examining  these  points  that  I  remarked  that  those  patients 
who  took  a  warm  bath  every  day,  a  remedy  in  which  I  have  great  faith  as 
a  source  of  comfort,  suffered  much  less  from  scalding  than  those  who  did 
not  use  it.  Struck  by  the  fact,  I  followed  it  up,  and  subsequently  ex- 
amined with  great  care  the  effects  of  abstinence,  water-drinking,  etc.,  on 
the  urine.  The  observations  made  were  far  too  extensive  for  insertion  here, 
and  therefore  I  only  give  the  results  in  as  compressed  a  form  as  possible. 
They  were  : — 

1.  That  the  action  of  the  warm  bath  proved  much  more  potent  than 
that  of  any  other  remedy,  therapeutic  or  hygienic,  but  that  it  only  lasted 
an  indefinite  time. 

2.  That  it  was  powerfully  seconded  by  great  moderation  in  the  use  of 
meat  and  a  proper  kind  of  diet,  and  that  the  best  palliatives  for  scalding 
are  water  and  mild  diuretics,  such  as  tea. 

Probable  Explanation  ;  Proposed  Plan  of  Treatment. — What  then  can  we 
glean  from  these  disjointed  observations  ?  Simply,  I  fear,  the  conviction 
that  empirical  practice  must  guide  us  till  chemistry  has  made  farther  pro- 
gress ;  and  on  this  assumption  I  shall  conclude  by  stating  what  deductions 
I  think  may  be  drawn  from  the  materials  brought  together. 

1.  We  have  good  reason  to  suppose  that  in  gonorrhoea  there  is  aug- 
mented action  and  more  rapid  development  of  urethral  epithelium ;  that 
this  augmented  action  (or  inflammation)  soon  casts  off  the  flattened  scales 
which  form  the  outer  surface  of  the  epithelial  covering  in  a  state  of  health, 
and  exposes  the  yet  tender  and  unflattened  cells,  gifted  perhaps  with  a 
much  greater  power  of  endosmosis  than  those  which  are  firm  and  com- 
pressed,  to  the  action  of  the  urine.     This  is  very  probably  the  reason 
why  the  canal  is  so  swollen  in  severe  gonorrhoea  ;    and  it  may  happen  that 
when  a  block  of  such  cells   is  suddenly  detached,  a  sore  place  ensues 
in  the   membrane,  or  the   unsupported  vessels  give   way  and  bleeding 
ensues. 

2.  That  the  scalding  is  owing,  not  so  much  to  the  action  of  the  acids 
of  the  urine  or  their  salts  on  the  abnormally  tender  membrane,  as  to  this 
abnormal  state  itself. 

11 


162  ON    GONORRHOEA. 

3.  That  the  ardor  urinoe  is  possibly,  so  far  as  it  is  dependent  on  the 
presence  of  an  acid  at  all,  due  to  the  phosphate  of  soda  acid,  though  it 
may  in  some  cases  and  to  some  extent  be  aggravated  by  the  presence  of 
lithic  acid,  as  an  excess  of  this  salt  will,  in  certain  disorders,  such  as  cold, 
influenza,  rheumatism,  and  gout,  of  itself  induce  scalding. 

4.  That  the  best  remedy  for  scalding  is  the  free  use  of  the  hot  bath, 
and  hot  bathing  to  the  penis  and  bladder  ;  moderate  abstinence,  and  the 
use  of  no  drink  but  water,  tea,  and  very  mild  diuretics  ;  while  at  the  same 
time  we  must  steadily  act  upon  the  disease,  and  look  chiefly  for  success  to 
subduing  it. 

2.  CHOKDEE. — Pathology. — Chordee  is  the  first  link  in  that  chain  of 
sympathetic  irritations  set  up  by  gonorrhoea,  which  from  their  resemblance 
to  inflammatory  phenomena  have  been  treated  antiphlogistically  by  many 
practitioners — I  allude  to  swelled  testicle,  irritable  bladder,  etc.  Probably 
the  affections  of  the  gland,  denominated  sympathetic  bubo,  mumps,  and 
gonorrhoea!  rheumatism,  the  two  former  of  which  bear  a  strong  resem- 
blance to  orchitis,  are  closely  allied  but  more  distant  phases  of  this  chain 
of  actions.  Violent  pain,  spasm,  indeed  all  the  symptoms  of  the  first  phase 
of  inflammation,  unable  to  pass  into  the  suppuratice  stage,  are  characteristic 
marks  of  these  affections  ;  the  analogues,  perhaps,  of  the  cough  and  sore- 
ness which  attend  the  acme  and  decay  of  some  disorders  of  the  mucous 
membranes,  such  as  cold  and  influenza. 

Chordee  has  been  divided  by  common  consent  into  inflammatory  and 
spasmodic  ;  but  while  the  origin  of  the  latter  has  been  silently  conceded 
to  muscular  contraction  or  orgasm  of  the  erectile  tissue,  that  of  the  for- 
mer has  been  rather  freely  contested. 

Hunter  says  : — "  When  the  inflammation  is  not  confined  merely  to  the 
surface  of  the  urethra  and  its  glands,  but  goes  deeper,  and  attacks  the  re- 
ticular  membrane,  it  produces  in  it  extravasation  of  coagulable  lymph  as  in 
the  adhesive  inflammation,  which,  uniting  the  cells  together,  destroys  the 
power  of  distention  of  the  corpus  spongiosum  urethrse,  and  makes  it  un- 
equal in  this  respect  to  the  corpora  cavernosa  penis,  and  therefore  a  curve 
on  that  side  takes  place  in  the  time  of  erection."  This  view  has  been  si- 
lently accepted  by  Durkee  and  others.  Sir  Charles  Bell,  who  with  all  his 
ability  is  scarcely  to  be  trusted  when  on  ground  previously  occupied  by 
Hunter,  limits  the  action  to  "  the  membrane  of  the  urethra,"  which  is  "  in- 
flamed, and  has  lost  its  elasticity;  being  powerfully  stretched  it  cracks," 
an  event  followed  by  bleeding.  To  this  M  Robert  adds  that  the  glands 
of  the  urethra  are  inflamed.  Mr.  "Wallace,  however,  says  that  it  is  the 
spongy  body  which  loses  "its  extensibility,  and  that  the  corpora  cavernosa 
are  not  affected  in  this  way,  the  proof  being  that  the  curve  takes  place  in 
the  direction  in  which  the  want  of  extensibility  of  the  corpus  spongiosum 
•would  act  on  the  corpora  cavernosa."  Mr.  Berkeley  Hill  thinks  the  cav- 
ernous and  spongy  bodies  are  imperfectly  distended,  while  according  to 


TREATMENT.  163 

Messrs.  Handfield  Jones  and  Sieveking, '  when  the  inflammation  extends  to 
the  fibrous  structure  of  the  corpus  spongiosum,  exudation  of  fibrine  some- 
times takes  place  in  the  venous  sinuses,  thus  occasioning  bending  of  the 
penis  toward  the  affected  part. 

However  ingenious  and  philosophical  these  explanations,  and  many 
others  which  I  have  omitted  for  want  of  space,  may  be,  it  is  manifest  that 
most  of  them  must  be  wrong,  for  they  are  in  flat  contradiction  to  each 
other  ;  while  there  is  not  one  of  them  which  can  be  looked  upon  as  proven  ; 
in  support  of  which  assertion  I  would  ask — 

1.  Is  there  on  record  a  single  case  in  which  it  was  shown,  on  post- 
mortem examination,  that  the  corpus  spongiosum  was  in  the  state  sup- 
posed— that  is,  containing  effused  lymph  ? 

2.  Is  there  one  which  proves  that  this  took  place  without  effusion  into 
the  upper  surface  of  the  urethra,  or  the  corpora  cavernosa  penis? 

3.  If  Sfr  Charles  Bell's  explanation  be  admitted,  how  comes  it  that  we 
can  bend  the  glans  penis  downward,  and  thus  relieve  the  chordee  ?    If 
the  mucous  membrane  had  lost  its  elasticity,  so  that  it  could  not  be  in- 
clined upward  without  pain,  how  could  it  be  thus  bent,  not  merely  with- 
out inducing  suffering  but  with  positive  relief  to  it  ? 

4.  Is  not  the  cause  of  the  erection  itself  a  disputed  point  ? 

5.  And  finally,  is  it  not  the  case  that,  when  adhesive  inflammation  at- 
tacks the  corpus  spongiosum,  very  intractable  and  totally  different  symp- 
toms and  results,  such  as  abscesses  opening  into  the  urethra  and  perma- 
nent adhesions,  are  met  with  ? 

The  grounds  I  urged  years  ago  for  refusing  to  accept  the  commonly  re- 
ceived explanations  have,  to  my  judgment,  only  gained  strength  with  time. 
Admitting  any  one  of  these  reasons  to  be  true — admitting  that  the  under 
part  of  the  urethra  has  lost  its  elasticity,  that  lymph  is  effused  into  the 
corpus  spongiosum,  and  not  into  the  corpora  cavernosa,  so  as  to  chain 
down  the  urethra— this  would  only  prevent  the  extension  of  the  penis.  In 
ordinary  erection,  that  part  of  the  urethra  which  is  the  seat  of  chordee  is 
carried  upward  nearly  unaltered  in  direction,  the  greatest  curvature 
taking  place  beyond  the  specific  seat  of  gonorrhoea.  Mere  effusion  of  lymph 
could  not  bend  the  urethra.  Besides,  supposing  such  effusion  to  have  really 
taken  place,  how  is  it  possible  that  both  the  bending,  and  the  pain  which 
it  occasions,  are  so  quickly  relieved  by  the  application  of  scalding  hot 
water?  I  might  well  ask,  whether  pathology  can  show  another  such  in- 
stance of  a  sudden  change  in  a  part  affected  with  adhesive  inflammation. 
Moreover,  I  have  never  been  able  by  manipulation  to  detect  the  effusion 
of  lymph  in  the  living  subject.  The  only  alteration  I  have  ever  remarked 
was  a  certain  hardness  in  the  middle  portion  of  the  urethra  ;  but  this  was 
toward  the  close  of  the  complaint,  and  more  likely  to  be  a  consequence  than 

1  Op.  citat. ,  p.  711. 


164  ON    GONOEEHCEA. 

a  cause  of  chordee.  Indeed,  I  feel  sure  that,  without  some  strange  neglect 
on  the  part  either  of  the  patient  or  surgeon,  adhesive  or  suppurative  in- 
flammation of  the  spongy  body  could  hardly  take  place.  On  the  other 
hand,  there  are  certain  facts  which  suggest  the  idea  of  its  being  due  to 
muscular  action.  The  first  is,  that  the  erection  of  the  penis  is  designed 
for  the  emission  of  semen,  and  is,  therefore,  one  stage  in  an  act  of  the  ani- 
mal economy,  obviously  performed  by  the  mixed  agency  of  voluntary  and 
organic  muscles.  The  second,  that  painful  erections,  which  are  but  one 
step  removed  from  spasmodic  chordee,  can  scarcely  be  caused  by  anything 
but  the  cause  of  healthy  erections.  The  third,  that  even  the  siipporters  of 
inflammatory  chordee  admit  that  there  is  a  spasmodic  chordee.  The 
fourth,  that  the  form  which  the  penis  assumes  in  chordee  is  much  more 
like  that  which  it  would  take  on  if  the  urethra  were  acted  upon  by  longi- 
tudinal muscular  fibres  seated  on  its  under  surface,  than  that  resulting 
from  a  solid  deposit  of  lymph,  which  could  scarcely  be  always  so  regularly 
effused  as  to  give  the  penis  the  same  form  in  every  case.  The  fifth,  that 
the  observations  made  by  Mr.  Bauer  and  Sir  Everard  Home,1  the  investi- 
gations of  M.  Kolliker  and  others,  and  the  discovery  by  Mr.  Hancock  of 
the  prolongation  of  the  muscular  coat  of  the  bladder  over  the  urethra, 
prove,  as  far  as  such  facts  can,  that  this  canal  may  be  acted  upon  by  spasm, 
and  the  so-called  specific  seat  of  gonorrhoea  is  certainly  comprised  within 
the  region  in  which  this  spasm  might  ensue. 

Dissection  of  the  penis  reveals,  in  connection  with  this  part,  a  cellular 
layer  uniting  the  corpus  spongiosum  to  the  corpora  cavernosa  above  an(5 
the  skin  below.  The  corpus  spongiosum,  which  appears  thicker  along  the 
under  than  on  the  upper  surface  of  the  urethra,  is  invested  by  its  owi? 
fibrous  sheath  and  invests  the  urethra.  It  contains  fibres  which,  when  ex. 
amined  under  the  microscope,  have  a  strong  resemblance  to  those  of  inor« 
ganic  muscle,  and  differ  widely  from  those  of  the  fibrous  sheath  of  the 
corpus  cavernosum;  these  fibres  grow  fewer  and  less  characteristically 
marked  as  the  corpus  spongiosum  expands  to  form  the  glans  penis.  I  am 
not  sufficiently  versed  in  the  use  of  the  microscope  to  say  with  certainty 
whether  they  are  muscular  or  not ;  but  Mr.  S.  F.  Lane,  who  kindly  as- 
sisted me  in  these  investigations,  and  who  was  quite  competent  to  form  an 
opinion,  thought  they  bore  a  strong  resemblance  to  muscular  fibre.  Even 
if  no  such  reasons  as  these  existed,  the  fact  previously  mentioned,  of  the 
urethra  easily  expelling  a  long  strip  of  calico,  shows  that  it  possesses  a 
muscular  power,  if  not  furnished  with  muscular  fibre,  which  is  most  as- 
suredly not  absolutely  necessary  for  such  actions,  as  the  anatomy  of  the 
smaller  animals  might  show. 

The  sixth  reason  is,  that  several  concomitant  and  similar  complications 
of  gonorrhoea,  such  as  irritability  of  the  bladder,  swelled  testicle,  abscess 

1  Practical  Observations  on  Stricture,  vol.  iii.,  p.  28.     1821. 


TREATMENT.  165 

•f  the  perineum,  and  sympathetic  bubo,  which  are  so  closely  connected  with 
chordee,  are  clearly,  at  all  events  in  the  early  stages,  much  more  like  spas- 
modic action  than  inflammation.  Irritability  of  the  bladder  is  spasm,  as 
evidently  as  anything  can  be ;  swelled  testicle  never  reaches  the  suppura- 
tive  stage  ;  for  though  now  and  then  abscess  may  follow  orchitis,  yet  it  is 
quite  a  different  affair  from  pure  suppurative  inflammation,  and  is  probably 
induced,  like  the  swelling  in  sympathetic  bubo,  by  the  secretion  of  the 
gland,  locked  up  by  spasm  of  the  efferent  duct,  acting  in  an  unhealthy  con- 
stitution like  a  foreign  body. 

It  is  only  right  to  add  that  the  arguments  just  employed  are  rejected 
by  Dr.  Bumstead.  He  says,  "  Milton's  explanation  is  opposed  by  the  fact 
that  bending  the  penis  so  as  to  increase  the  curve  of  the  arc  affords  partial 
ease  to  the  pain  of  the  chordee,  and  I  am  not  convinced  that  the  generally 
received  opinion  should  thus  be  laid  aside,  though  it  is  highly  probable  that 
spasmodic  muscular  action  plays  some  part  in  the  production  of  the  fre- 
quent erections  and  chordee  which  take  place  in  gonorrhoea." 

Prognosis. — Favorable  when  the  affection  is  promptly  met ;  but  if 
treated  lightly  or  left  to  nature,  and  so  allowed  to  get  hold  of  the  struct- 
ures, it  may  prove  very  troublesome,  as  will  be  seen  by  what  follows. 

Results. — I  have  seen  mismanaged  chordee  followed  by  very  disagree- 
able and  protracted  pain  on  erection,  continuing  long  after  the  gonorrhoea 
had  disappeared.  One  patient,  a  medical  man,  suffered  in  this  way  for 
quite  six  or  seven  years.  He  had  done  nothing  beyond  taking  a  few 
copaiba  capsules  for  his  complaint.  But  much  worse  after-effects  have 
been  seen.  Death  occurred  in  the  practice  of  M.  Villeneuve.1  The  patient 
was  suffering  from  intense  chordee  and  continual  erection,  to  relieve  which 
twenty  leeches  were  applied.  Two  days  after  a  scab  formed  on  the  most 
prominent  part  of  the  curve  ;  when  it  fell  off  the  cavernous  bodies  were 
exposed  for  a  length  of  three  or  four  centimetres.  Rigors,  pains  in  the 
joints  of  the  upper  limbs,  purulent  effusion  into  the  left  elbow-joint,  and 
delirium  followed,  with  arterial  hemorrhage  from  the  slough  on  the  penis 
which  carried  the  patient  off.  Phlebitis  of  the  prostatic  plexus,  metastatic 
abscess  in  the  left  lung  and  liver,  and  effusion  of  matter  into  the  elbow- 
joint  were  found  after  death.  M.  Dron  2  had  a  case  where  the  patient  was 
in  the  habit  of  injecting  himself  for  a  gonorrhoea,  having  done  so  for  two 
years,  without  however  laying  any  restrictions  upon  his  habits.  Under 
this  management  the  urethra  had  become  tense  during  erection,  constitut- 
ing indeed  the  string  of  a  bow,  the  curve  of  which  was  formed  by  the 
dorsal  side  of  the  penis.  Rupture  of  this  took  place  during  connection, 
and  a  very  considerable  quantity  of  blood  passed  by  the  urethra.  Very 
shortly  after  the  scrotum  began  to  swell,  and  the  patient  could  pass  only  a 
small  quantity  of  water.  When  M.  Dron  saw  him  the  scrotum  was  as 

1  Gazette  Hebdomadaire,  p.  210.     1ST:',. 

9  Lyon  Medical.     Quoted  in  Gazette  des  Hopitaux,  p.  950.     1877. 


166  ON    GONORRHOEA. 

large  as  the  head  of  a  child  three  months  old,  tense,  and  of  a  violet  color. 
The  tumefaction  ascended  toward  the  groin,  and  reached  the  abdominal 
walls.  The  patient  was  much  prostrated.  The  pulse  was  small,  rigors 
were  present,  and  a  smell  of  urine  was  exhaled  from  the  body.  The  scro- 
tum was  laid  open,  and  a  large  quantity  of  bloody  serum  let  out,  but  gan- 
grene of  a  large  portion  of  the  scrotum  took  place,  laying  bare  the 
testicles ;  abscess  was  set  up  in  the  left  groin,  and  a  fistulous  opening 
formed  in  the  urethra  about  three  inches  (eight  centimetres)  from  the 
orifice.  "When  this  closed,  contraction  ensued  at  the  spot,  which  required 
internal  urethrotomy. 

Treatment  usually  adopted. — To  judge  by  modern  practice,  the  faith  of 
medical  men  in  their  own  pathology  seems  to  be  at  something  like  zero  ; 
for  to  meet  inflammatory  conditions  of  various  tissues  and  deposit  of 
lymph  with  antispasmodics  and  sedatives  argues,  to  my  thinking,  great 
want  of  confidence  indeed.  Yet  this  is  the  treatment  which  is  now  almost 
universally  recommended.  M.  Ricord  prescribes  gr.  ijss.  of  camphor,  and 
gr.  ss.  of  opium,  in  a  pill,  of  which  two  or  three  may  be  taken  every  night. 
He  also  suggests  the  employment  of  the  extract  of  lettuce  in  doses  of  eight 
to  twelve  grains  with  an  equal  weight  of  camphor.  But  the  bulk  is  ob- 
jectionable ;  these  quantities  make  from  four  to  six  large  pills,  or  else  a 
bolus,  and  most  persons  dislike  such  large  doses  of  solids.  Mr.  Johnson 
says,  :l  opium,  in  some  form,  can  rarely  be  dispensed  with  ; "  he  thinks 
the  "  Dover's  powder  is  as  good  a  preparation  as  any,"  and  "  was  never 
thoroughly  convinced  that  the  camphor  had  much  to  do  with  any  benefits 
obtained."  Dr.  Bumstead  gave  lupulin  and  camphor.  Durkee  strongly 
recommended  lupulin ;  he  considered  it  far  preferable  to  camphor,  as  it 
does  not  disagree  with  ^the  stomach.  Against  the  agreeable  qualities  of 
lupulin  must  be  set  its  inferior  power,  even  when  prepared  from  the  best 
golden  hops  and  by  a  careful  chemist.  Mr.  Berkeley  Hill  tells  us,1  that 
strychnine,  recommended  for  this  sympton  by  Mr.  Henry  Lee,  sometimes 
acts  very  beneficially  and  in  other  cases  fails  entirely.  Mr.  Lee,  however, 
does  not  mention  strychnia  in  his  article  on  gonorrhoea  in  "  Holmes' 
System  of  Surgery."  He  recommends  camphor,  and  bathing  with  hot 
water  to  faintness  before  going  to  bed ;  but  considers  that,  perhaps,  the 
most  efficacious  remedy  is  a  suppository  containing  a  grain  of  opium  and 
three  of  camphor.  Dr.  Parona  seems "  to  have  had  great  success  in  re- 
moving chord  ee,  sensibility  of  the  urethra,  scalding  and  weight  in  the 
perineum,  by  means  of  daily  injections  of  hydrate  of  chloral,  one  to  one 
and  a  half  per  cent,  of  the  salt  in  water ;  and  M.  Cambillard  equally  great 
with  injections  of  bromide  of  potassium,  6  gr.  to  150  of  water  and  10  of 
glycerine.3 


1  Op.  citat  ,  p.  394.  sGiorn.  Italiano,  an.  vlii.,  p.  279.     1873. 

3  Journal  de  Therapeutique,  October  25,  1881.   Quoted  in  Glasgow  Medical  Journal, 
p.  72.     1882. 


TREATMENT.  167 

Proposed  Plan  of  Treatment. — The  possibility  of  allaying  chordee 
merely  by  the  use  of  antispasmodics  does  not  seem  to  have  been  enter- 
tained before  the  first  edition  of  this  work  appeared.  It  is,  however,  pre- 
cisely this  part  of  the  subject  which  has  most  of  all  occupied  my  atten- 
tion ;  and  I  trust  I  have  substituted  a  simple  remedy  for  complicated 
methods.  Sedatives  are  objectionable  unless  there  be  pain  in  the  testicle 
or  perineum,  as  they  disorder  the  stomach  and  produce  headache  and 
languor,  with  constipation  of  the  bowels,  a  state  of  matters  often  followed 
by  exacerbation  of  the  disorder  ;  while  the  chordee  is  not  so  speedily 
checked  as  by  a  remedy  which  acts  on  the  spasm,  and  often  returns  as  soon 
as  sedatives  are  no  longer  given. 

After  having  tried  almost  every  antispasmodic,  including  ether,  chloro- 
form, and  sumbul,  I  can  safely  say  that  I  have  found  nothing  equal  to 
camphor  in  the  fluid  form,  as  recommended  by  me  in  the  first  edition  of 
this  work.  In  the  solid  state  it  does  not  act  so  rapidly ;  and,  in  fact,  a 
remedy  in  a  liquid  form — as  it  must  from  its  extremely  fine  state  of  divi- 
sion act  more  rapidly — is  more  suited  for  spasm.  The  spirit  of  camphor 
offers  all  the  advantages  sought  for,  and  given  in  drachm  doses  is  equally 
energetic  and  rapid  in  its  action.  The  essence  of  camphor,  prepared  by 
Messrs.  Slinger  &  Barnet,  of  York,  which  is  perfectly  miscible  with  water, 
is  a  much  more  agreeable  medicine,  but  more  expensive  and  weaker. 
What  is  now  made  by  chemists,  under  this  name,  seems  to  possess  no  par- 
ticular advantage  over  the  spirit. 

Chordee  cannot  be  cured  too  quickly,  and  Boerhaave  showed  what  a 
sound  physician  he  was  when  he  said  that  he  who  was  most  successful  in 
preventing  priapism  will  be  most  successful  in  the  cure  of  the  disease.  As 
in  many  other  cases,  the  chain  of  morbid  action  should  be  broken  at  once, 
and  this  is  much  more  effectually  done  by  giving  two  or  three  full  doses, 
at  short  intervals  without  the  least  remission,  than  by  small  quantities, 
however  long  continued  and  regularly  taken.  The  surgeon  may  there- 
fore safely  adopt  the  following  plan :  Half  a  teaspoonful  to  a  teaspoonful 
of  the  spirit  is  to  be  taken  at  night  in  water  before  going  to  bed,  and 
every  time  the  patient  wakes  with  the  chordee,  let  him  at  once  rise  and  re- 
peat the  dose.  In  mild  cases,  one  dose  for  a  night  or  two  is  generally 
enough  ;  and  even  in  more  severe  cases  the  spasm  is  usually  very  much 
alleviated  by  the^  third  or  fourth  night.  So  long  as  the  chordee  remains 
very  bad,  which  will  not  often  be  more  than  five  or  six  nights  if  the  patient 
be  reasonably  attentive,  he  may  take  a  dose  before  going  to  bed.  This 
remedy  also  answers  well  in  the  bearing-down  pains  to  which  women  are 
sometimes  subject  in  gonorrhoea,  but  as  these  pains  are  generally  worst  in 
the  daytime,  the  medicine  may  be  given  then  ;  and  here  it  is  really  a  mat- 
ter of  convenience  to  use  the  York  essence  of  camphor,  as  it  mixes  well 
with  any  medicine  they  may  happen  to  be  taking. 

In  both  cases,  however,  it  must  be  given  in  full  doses.     A  smaller  quan- 


168  ON    GONORRHffiA. 

tity  than  half  a  teaspoonful  of  either  the  ordinary  essence  or  spirit  is  of 
little  service ;  generally  a  teaspoonful  is  required,  and  as  this  quantity  is 
perfectly  safe,  it  is  best  to  insure  success  at  once.  In  a  few  instances  it 
has  produced  slight  sickness.  This,  however,  has  not  occurred  very  often, 
and  the  sickness  was  of  little  moment,  so  that  I  only  allude  to  the  fact, 
lest  any  one  might  be  discouraged  by  the  appearance  of  this  symptom, 
from  administering  so  valuable  a  remedy.  The  patient  should  be  directed 
to  keep  the  camphor  in  a  tightly  corked  bottle,  and  to  have  it  at  night  by 
his  bedside  ready  to  take.  It  can  be  taken  in  water  ;  the  sweetened  milk, 
however,  recommended  by  Dr.  Durkee,  is  really  an  excellent  vehicle,  and 
one  which  is,  owing  to  the  general  introduction  of  tinned  milk,  easily  ac- 
cessible. The  old  essence  requires  no  addition  beyond  water. 

I  believe  few  who  have  given  camphor  in  this  form  a  fair  trial  have 
come  to  a  different  conclusion  from,  myself.  Irrespective  of  communica- 
tions I  have  received  on  the  subject,  I  know  from  the  prescriptions  I  have 
seen  that  it  is  now  constantly  used  by  many  surgeons.  Dr.  Bumstead ' 
and  Mr.  Henry  Lee2  distinctly  testify  to  its  value.  As  to  the  objection 
raised  by  the  late  Mr.  Weeden  Cooke,  that  both  opium  and  camphor  dis- 
turb the  brain  and  stomach,  it  does  not  here,  as  a  rule,  affect  the  giving  of 
the  latter.  The  disturbing  influence  of  opium  I  am  quite  prepared  to  ad- 
mit, but,  generally  speaking,  camphor  is  pretty  well  borne  for  the  short 
time  required  to  subdue  chordee,  and  even  for  the  much  longer  period 
during  which  spermatorrhoea  patients  have  to  take  it.  No  doubt,  as  has 
just  been  said,  some  persons  do  not  support  it  well,  but  they  are,  even  if 
numerous,  exceptions,  whereas  opium  in  full  doses  generally  disagrees 
here.  In  orchitis,  on  the  other  hand,  it  has  usually  appeared  to  me  that 
at  the  first  outset  we  could  hardly  give  too  much  opium.  The  pain  of 
chordee  seems  dependent  on  a  kind  of  spasm,  a  state  often  not  acted  on  by 
sedatives  ;  in  orchitis  the  nature  of  this  symptom  more  nearly  approaches 
that  of  true  inflammation,  on  which  opiates  sometimes  act  very  beneficially. 
When  camphor  does  disagree  it  generally  brings  on  a  feeling  of  heat  in  the 
throat  and  stomach,  with  sickness. 

Bromide  of  potassium  seems  to  have  been  very  serviceable  in  the  hands 
of  some  observers,3  especially  in  obstinate  priapism  following  gonorrhoaa. 
Dr.  Soresina  gave  it  with  great  success  in  a  case 4  which  had  resisted  every 
remedy  for  eight  months.  I  have  not  tried  it  in  this  form,  but  from  what  I 
observed  of  its  action  in  chordee,  I  should  not  feel  inclined  to  prefer  it  to 
camphor.  Occasionally,  when  the  patient  has  not  liked  camphor  alone,  I  have 
prescribed,  with  success,  a  draught  with  fifteen  to  twenty  grains  of  bromide 
of  potassium,  five  grains  of  hydrate  of  chloral,  and  two  drachms  of  brandy, 

1  New  York  Journal  of  Medicine,  vol.  ii. ,  p.  223.     1859. 

8  Holmes'  System  of  Surgery,  second  edition,  vol.  v.,  p.  208. 

3  Practitioner,  vol.  xii. ,  p.  103. 

4Appendice  sifilitica  della  Gazett.  Med.  Lombard.     Ago,  1862. 


TREATMENT.  169 

with  a  little  essence  of  camphor  in  strong  peppermint  water.  The  bleeding 
which  results  from  mismanaged  chordee  scarcely  ever  requires  any  internal 
treatment,  nothing  being  needed  beyond  exposure  of  the  parts  to  the  open 
air. 

3.  SYMPATHETIC  BUBO. — It  is  not  necessary  to  dwell  on  this  symptom, 
which  rarely  attains  such  severity  as  to  justify  any  interruption  in  the 
treatment.     Hot  bathing  will  generally  relieve  it  so  quickly,  that  the  sur- 
geon need  scarcely  trouble  himself  to  prescribe  any  local  remedies.     I 
therefore  leave  it  to  pass  to  another  more  severe  complication. 

4.  IEEITABLE  BLADDER. — I  am  afraid  of  being  charged  with  exaggeration 
for  saying,  that  if  the  treatment  recommended  for  gonorrhoea  in  the  earlier 
part  of  this  work  be  enforced,  irritable  bladder  will  rarely,  if  ever,  occur 
to  such  an  extent  as  to  cause  the  patient  any  material  inconvenience. 
Such,  however,  is  the  fact. 

But  it  frequently  happens  that  we  do  not  see  the  patient  till  this  com- 
plication has  set  in,  and  then  the  surgeon  will  often  exhaust  all  his  re- 
sources in  vain,  while  on  the  other  hand  he  may  relieve  the  patient  with 
the  first  remedy  he  selects.  I  have  experimented  with  every  form  of  seda- 
tive and  antispasmodic,  including  hydrocyanic  acid,  valerian,  steel,  bis- 
muth, sumbul,  and  galbanum,  without  finding  any  remedy  upon  which  I 
could  rely,  so  that  I  have  been  compelled  to  return  to  the  preparations  of 
opium  ;  not  that  they  are  certain  remedies,  but  that,  cceteris  paribus,  they 
are  the  best.  I  think  they  are  best  given  by  the  mouth.  I  tried  opium 
suppositories,  but  the  results  were  not  encouraging  ;  those  of  morphia  and 
atropine,  gr.  £  and  gr.  ^  mixed,  are  said  to  act  admirably.  Antiphlogis- 
tics,  leeching  included,  have  always  in  my  experience  proved  useless,  even 
when  the  irritation  had  developed  into  a  certain  degree  of  cystitis. 

In  the  irritable  bladder  which  results  from  extension  of  the  inflamma- 
tion of  gonorrhoea  Sir  Henry  Thompson  advises '  the  use  of  the  triticum 
repens  or  couch  grass,  as  superior  in  certain  cases  even  to  the  buchu.  It 
is  given  in  the  form  of  infusion,  an  ounce  of  the  underground  stem  to  a 
pint  of  boiling  water ;  he  advises  that  the  stem  should  be  gathered  in 
spring  before  the  leaves  appear,  and  dried  slowly  without  heat.  It  is  mild, 
and  by  no  means  unpleasant,  so  that  a  pint  of  the  infusion  may  be  given 
in  the  course  of  the  day.  Sir  Henry  now  says 2  that  the  remedy  still  main- 
tains its  credit.  Mr.  John  Simon,  in  sympathetic  irritation  of  the  bladder, 
that  is  where  the  inflammation  has  not  travelled  so  far  as  the  viscus,  re- 
commends 3  a  bougie,  "smeared  with  nitrate  of  silver,"  to  be  applied  to  the 
first  two  or  three  inches  of  the  urethra.  In  the  other  form  relief,  he  tells 
us,  is  given  by  the  hip-bath,  recumbent  position,  and  opiate  clysters.  "Mr. 
Teevan  considers  that  in  all  cases  of  irritable  bladder  there  is  incipient 

1  Lancet,  vol.  ii.,  p.  345.     1861. 

2  Clinical  Lectures  on  Diseases  of  the  Urinary  Organs,  p.  199. 
3 Lancet,  vol.  i.,  p.  289.     1850. 


170  ON    GONORRIKEA. 

stricture,  but  the  way  in  which  I  would  put  the  proposition  is  this,  that 
when  the  gonorrhoea!  inflammation  extends  backward  with  severity  enough 
to  set  up  stricture,  it  often  enough  spreads  as  far  as  the  neck  of  the  bladder 
and  makes  this  organ  irritable.  I  am  sure  that  the  incipient  stage,  spoken 
of  by  Mr.  Teevan,  very  often  comes  to  nothing,  for  I  have,  months  and  even 
years  after,  passed  the  bougie  and  found  the  passage  quite  free. 

5.  ORCHTTIS. — Pathology. — This  affection  has  been  supposed  to  arise 
from  metastasis,1  erratic  disposition  of  the  gonorrhoea!  inflammation,  sym- 
pathy, and  continuous  spreading  of  the  disease  along  the  urethra.  Nearly 
all  modern  authors  admit  the  two  last  varieties.  But  the  doctrine  of  sym- 
pathy rests  on  mere  conviction  ;  it  is  unsupported  by  either  analogy  or  proof. 
Moreover,  we  do  not  see  anything  of  the  kind  in  other  affections  of  the 
mucous  membranes.  Even  those  who  admit  this  view  are  obliged  to  con- 
fess that  sometimes  the  inflammation  spreads  along  the  urethra  ;  a  surmise 
proved  by  the  cases  which  Cooper,  Ricord,  Gay,  and  others  have  placed 
upon  record.  But  several  symptoms  concur  to  make  it  almost  certain  that 
this  is  always  the  fact.  Tenderness  at  different  parts  of  the  urethra,  as 
far  back  as  the  prostate,  is  constantly  being  detected  in  such  cases.  Pain 
in  the  perineum  and  tenderness  in  the  vas  deferens  very  frequently,  spas- 
modic stricture  and  great  irritability  of  the  bladder  not  unfrequently,  pre- 
cede swelling  of  the  testicle,  and  orchitis  often  follows  from  irritation  of 
these  parts,  as  when  it  occurs  from  stricture  or  stone.  No  doubt  at  the 
beginning,  and  in  mild  cases,  the  first  inch  and  a  half  may  be  looked  upon 
as  the  seat  of  gonorrhoea!  inflammation,  or  rather  the  part  to  which  it  is 
mainly  confined  ;  but  later  on  and  in  irritable  constitutions,  the  circum- 
stances under  which  we  encounter  orchitis,  the  case  is  very  different. 

It  is  not  at  all  uncommon  for  gonorrhoea,  even  in  cases  unaccompanied 
by  orchitis,  to  extend  at  least  five  or  six  inches  down  the  urethra,  and  even 
quite  to  the  bladder.  It  is  true  that  the  history  of  the  case  may  reveal 
nothing  which  points  to  this  conclusion  ;  sensation  is  often  so  dull  in  the 
posterior  portion  of  the  spongy  part  that  in  many  persons,  after  a  bougie 
has  passed  the  first  two  inches  or  so,  they  cannot  tell  within  an  inch  where 
the  point  is  ;  but  a  very  simple  experiment  will  often  show,  that  though 
the  sensation  may  reveal  nothing,  the  inflammation  has  reached  as  far  as 
I  have  said.  The  surgeon  has  only,  in  a  few  bad  cases  of  obstinate  gon- 
orrhoea or  gleet,  to  syringe  out  the  urethra  with  cold  water  up  to  the  pos- 
terior end  of  the  so-called  specific  seat  of  the  disease,  and  then  direct  the 
patient  to  make  water  ;  in  a  certain  proportion  of  these  cases  a  shred  or 
two  of  muco-pus  will  be  expelled  with  the  urine.  Again,  if  a  bougie  be 
passed  down  the  urethra  for  two  or  three  inches,  withdrawn,  wiped  clean, 
and  passed  down  to  the  membranous  or  prostatic  portion  of  the  urethra,  a 
shred  or  two  of  the  kind  spoken  of  will  often  be  found  adhering  to  it  when 


1  Brodie  :  Works,  vol.  ii.,  p.  262. 


TREATMENT.  l7l 

withdrawn  the  second  time.  In  obstinate  gleet  the  bougie,  when  passing 
over  the  posterior  portion  of  the  urethra  often  encounters  tender  spots  ; 
with  the  removal  of  this  tenderness  the  gleet  ceases.  Injecting  over  the 
posterior  part  of  the  urethra  will  often  cure  gleets  which  injections  of  every 
kind,  applied  only  to  the  anterior  part  of  the  same  canal,  have  totally  failed 
to  touch. 

In  short,  we  see  in  all  the  phenomena  of  orchitis  the  disease  passing 
along  continuous  and  through  contiguous  structures,  just  as  in  other  parts  ; 
nothing  which  tells  us  that  the  two  extreme  points  of  the  membrane  are 
inflamed,  and  the  tract  between  them  sound.  The  probability  is  that  the 
sympathetic  variety  described  by  Ricord,  Curling,  Egan,  and  others,  is 
simply  a  mild  form  of  extension  of  the  inflammation  ;  those  parts  which 
intervene  being,  from  their  low  organization,  incapable  of  active  disease  of 
this  kind  ;  it  being  well  known  to  surgeons  that  the  portion  of  the  urethra 
between  the  specific  seat  of  gonorrhoea  and  the  membranous  tract  is  much 
less  sensitive  than  these  regions. 

The  older  surgeons  knew  this  as  well  as  modern  writers.  Indeed  Sir 
Astley  Cooper  described '  orchitis  as  beginning  with  irritation  of  the  mem- 
branous or  prostatic  portion  of  the  canal,  and  tenderness  of  the  spermatic 
cord.  Mr.  Hunter  alludes  to  similar  facts.  Swediaur  maintained  a  that 
orchitis  was  due  to  the  "  poison  "  reaching  the  mouths  of  the  "  excretory 
ducts,"  and  Bell  and  Civiale  pointed  out  the  affection  of  the  cord.  John- 
son gives  an  analysis  of  fifty-nine  cases,  in  twelve  of  which  the  symptoms 
of  urethritis  were  entirely  gone  before  the  orchitis  came  on ;  so  that  in 
one-fifth  of  the  entire  number  there  was  no  sympathy,  and  the  evidence  of 
MM.  Castelnau  and  Aubiy  is  to  the  effect  that  this  complication  may  ap- 
pear from  five  days  to  three  months  after  the  cessation  of  the  discharge. 

Inflammation  of  the  testicle  rarely  occurs  in  the  first  week  or  two  of 
gonorrhoea,  when  these  symptoms  are  most  severe  and  most  likely  to  occa- 
sion sympathy,  while  it  never  ensues  till  a  sufficient  interval  has  elapsed  to 
allow  of  such  an  active  disorder  spreading  backward  over  so  short  a  space. 
To  call  attention  so  often  to  this  may  s^em  needless  repetition,  but  where 
a  widespread,  and  what  is  thought  to  be  a  wrong,  belief  exists,  the  ques- 
tion is,  not  what  is  the  most  scientific,  but  what  is  the  most  effectual,  mode 
of  dealing  with  it.  Dr.  Bumstead  says  most  authorities  admit  that  swelled 
testicle  may  be  excited  through  sympathy  alone,  and  that  the  subsidence 
of  the  swelling  in  one  testicle  and  its  subsequent  appearance  in  the  other, 
as  occasionally  happens,  render  this  view  probable.  It  is  not  often  that  I 
find  myself  in  direct  opposition  to  this  careful  observer,  but  I  do  here. 
My  reply  is,  firstly,  that  authorities  are  often  wrong,  and  secondly,  that 
inflammation  may  clearly  reach  both  testicles  by  the  same  road  as  it 
reaches  one. 

1  On  the  Structure  and  Diseases  of  the  Testis,  part  ii. ,  p.  8. 

2  Op.  citat.,  p.  73. 


172  ON    GONORBHCEA. 

Balanitis  is  said  by  Ricord  never  to  give  rise  to  orchitis.  I  have  seen 
one  instance  of  it  from  this  source  ;  the  patient,  however,  admitted  that  he 
had  practised  masturbation.  The  case  was  a  very  bad  one  ;  the  prepuce 
was  of  a  violet  color,  and  so  swollen  that  an  accurate  examination  could 
not  be  made.  The  patient  wore  a  most  unhealthy  appearance.  In  forty- 
eight  hours  after  commencing  attendance  for  balanitis,  swelled  testicle 
came  on  ;  no  trace  of  gonorrhoea  was  detected  during  the  time  I  saw 
him. 

While  in  this  affectidn  we  have  every  sign  of  active  inflammation,  pain, 
heat,  redness,  etc.,  it  has  been  doubted  by  some  authors  whether  the  testi- 
cle is  really  inflamed.  The  epididymis  is  to  be  considered  the  head-quar- 
ters of  the  disease,  which  is  to  be  named  accordingly  ;  and  we  are  to  look 
upon  the  affection  of  the  testicle  as  a  mere  subordinate  affair,  for  no  other 
reason,  that  I  can  learn,  than  because  the  pain  and  swelling  begin  at  the 
epididymis.  But  this  seems  simply  due  to  the  inflammation  having  in  its 
progress  again  reached  a  susceptible  point.  From  the  tone  in  which  this 
doctrine  is  urged  by  some  writers,  it  might  be  looked  upon  as  a  modem 
discovery.  It  was,  however,  upheld  by  Swediaur,1  at  any  rate  as  regards 
the  outset  of  the  complaint,  and  where  it  had  not  been  improperly  treated ; 
while  Howard  contested  it,2  and  Hunter  refuted  it 3  long  ago.  M.  Salleron, 
in  a  thoroughly  practical  memoir  on  orchitis,4  strongly  opposes  M.  Ricord's 
doctrine  of  the  inflammation  being  forty-nine  times  out  of  fifty  limited  to 
the  epididymis,  and  states,  emphatically,  that  he  has  very  rarely  seen  it 
thus  restricted  ;  besides,  it  seems  to  me  that  the  relief  afforded  in  many 
cases  by  puncture  of  the  body  of  the  testicle,  and  by  the  application  of 
ether  and  ammonia  to  this  part,  is  of  itself  enough  to  show  that  there 
must  have  been  some  error  in  M.  Ricord's  observations.  It  is  certainly 
quite  probable  that  the  epididymis  is  the  part  most  severely  affected,  and 
that  the  body  of  the  testicle  is  not  often  highly  inflamed  ;  but  the  extreme 
tenderness  of  the  gland,  the  great  prostration,  and  'other  symptoms,  ren- 
der it,  I  think,  almost  certain  that,  in  every  severe  case,  the  whole  organ  is 
invaded,  and  that  it  seldom  escapes  in  the  mildest. 

M.  Gosselin  considers 6  that  in  most  cases  of  epididymis  the  vaginal 
tunic  is  also  inflamed.  We  may,  I  think,  assume  that  such  is  the  case, 
when  we  observe  how  distinctly  the  scrotum  is  affected  in  this  way  and 
how  irritable  the  dartos  is  ;  but  I  am  not  at  all  disposed  to  view  them  as 
independent  affections.  They  seem  to  me  purely  secondary,  the  parts 
being  sucked  into  the  vortex  of  the  inflammation  by  sympathy  of  contigu- 
ity. M.  Rochoux,  reporting '  on  a  paper  on  this  subject  by  M.  Ricord, 
maintains  that,  a  small  portion  of  the  tumor  excepted,  which  belongs  to 

1  Op.  citat.,  p.  74.  8  Op.  citat.,  vol.  i.,  p.  215.  8  Op.  citat.,  p.  55. 

4  Archives  Generates  de  Medecine,  tome  i.,  p.  174.     1870. 

6  Gazette  des  Hopitaux,  p.  434.     1873. 

6  Bulletin  de  1'Academie  de  Medecine,  vol.  ii.,  p.  506.     1838. 


TREATMENT.  173 

the  epididymis,  the  swelling  is  entirely  formed  by  effusion  into  the  tunica 
vaginalis.  But  this  could  not  be  effusion  in  the  ordinary  sense  of  the 
term,  for  the  enlargement  sometimes  disappears  more  rapidly  than  serum 
is  ever  absorbed  ;  and  the  covering  itself  has  been  repeatedly  pierced  with- 
out yielding  more  than  a  few  drops  of  fluid. 

Perhaps  no  man  has  examined  the  subject  so  fully  as  M.  Castelnau.1 
According  to  him  the  post-mortem  appearances  found  by  Gaussail  in  the 
first  of  three  cases  were,  vas  deferens  augmented  in  size  throughout,  its 
capacity  diminished  and  obstructed  by  yellowish  white  matter  ;  little  ves- 
sels ramified  on  its  walls  more  red  than  usual.  Epididymis  voluminous,  of 
a  red  hue  like  wine  lees  ;  in  its  centre  a  deposit  of  matter  like  that  in  the 
deferent  canal.  The  testicle  only  displayed  marked  injection  of  the  ves- 
sels ramified  through  its  thickness.  The  vaginal  tunic  contained  a  little 
reddish  serum.  In  the  two  other  cases  the  appearances  were  much  the 
same,  except  that  those  in  the  testicles  were  more  pronounced  ;  while 
Castelnau,  in  a  case  which  he  examined,  found 2  the  vas  deferens  moder- 
ately swollen,  but  only  for  the  length  of  an  inch  and' a  half  from  its  infe- 
rior extremity  ;  the  epididymis  about  double  its  normal  size,  hard  and 
reddish;  the  vessels  of  the  testicle  very  much  injected,  while  the  gland 
contained  in  its  interior  three  small  masses  of  unorganized  matter,  less 
consistent  and  more  moist  and  translucent  than  tubercle. 

Causes. — With  respect  to  the  action  of  injections  in  producing  orchi- 
tis,  I  must  refer  the  reader  to  the  section  on  injections.  As  to  the  influ- 
ence of  specifics,  I  can  scarcely  be  expected  to  give  an  unprejudiced  opin- 
ion, as  I  use  these  medicines  so  little.  I  must  leave  the  task  to  others, 
and  the  sooner  some  one  undertakes  it  the  better.  Mr.  Johnson  blames 
cubebs,  copaiba,  and  injections  indiscriminately.  Mr.  Curling  defends 
the  two  former,  and  grants  the  demerits  of  injections  used  improperly. 
Broughton  defends  cubebs ;  Sir  B.  Brodie,  cubebs  and  injections.  Swe- 
diaur  admits  irritating  and  astringent  injections  as  causes ;  Wallace  and 
Robert  take  up  the  cudgels  in  favor  of  all  the  three ;  Hunter  and  Sir 
Astley  Cooper  thought  irritating  injections  might  induce  swelled  testicle  ; 
Egan  admits  the  injudicious,  but  not  the  judicious,  use  of  injections  as  the 
origo  mali.  Dr.  Frazer,  a  most  careful  observer,  says  he  has  never  seen 
any  reason  to  connect  the  occurrence  of  orchitis  with  injections  ;  Dr.  Dur- 
kee  thinks 3  strong  injections  frequently  produce  orchitis,  but  that  those 
of  moderate  strength  do  noi  Eicord,  taking  his  stand  on  statistics,  de- 
clares that  he  found  only  one  orchitic  patient  in  twenty  had  been  taking 
gonorrhoea!  remedies  ;  M.  le  Fort,  analyzing  an  enormous  number  of  cases, 
denies,  as  I  understand  him,  the  influence  of  treatment,  especially  in  re- 
spect to  injections.  Now  if  any  person  can  draw  a  conclusion  from  this 

1  Annales  des. Maladies  de  laPeau,  p.  193.    1844. 
s  Op.  citat.,  p.  194.  3Op.  citat.,  p.  83. 


174  ON    GONOKBHCEA. 

mass  of  contradictions,  I  should  be  glad  to  know  what  solution  of  the  diffi- 
culty he  has  to  offer. 

The  influence  of  cold,  wet  weather  has  also  been  advanced  as  a  cause 
of  orchitis. '  Being  anxious  to  investigate  the  point,  and  considering  that 
the  experience  of  one  person  could  not  suffice  to  determine  it,  I  examined 
the  entries  in  the  casualty  and  out-patients'  books  in  three  hospitals/  two 
of  which  are  among  the  largest  in  London.  The  years  1852  and  1853 
were  selected,  simply  because  they  coincided  with  the  period  at  which 
some  other  observations  were  made.  The  number  of  cases  obtained  will, 
it  is  hoped,  be  large  enough  to  prevent  the  deductions  being  vitiated  by 
accidental  causes.  Some  of  them  are  necessarily  imperfect,  and  occasion- 
ally entries  were  met  with  which  rendered  it  doubtful  if  they  referred  to 
cases  of  genuine  orchitis,  but  in  our  present  state  of  knowledge  the  same 
objections  might  be  raised  against  all  statistics  of  this  kind. 

In  making  these  researches  I  was  most  kindly  and  courteously  assisted 
by  the  authorities,  to  whom  I  applied  for  leave  to  search  the  case-books, 
etc.,  as  well  as  by  the  assistant-surgeons  and  house-surgeons ;  indeed, 
without  their  aid  I  could  not  possibly  have  drawn  up  these  tables.  Dr. 
Fair,  too,  very  courteously  gave  me  every  facility  for  searching  the  returns 
of  the  Registrar-General  preserved  at  Somerset  House. 

The  returns  in  the  third,  fourth,  and  fifth  columns,  it  will  be  observed, 
contain  the  numbers  of  cases  of  orchitis  occurring  at  each  hospital ;  that 
in  the  sixth  column,  the  total  in  all  the  hospitals  for  the  week.  The  rea- 
son for  arranging  the  number  of  cases  according  to  the  weeks,  and  for  be- 
ginning with  the  4th  of  January  instead  of  the  1st,  is,  that  the  hospital 
returns  might  tally  with  those  of  the  Registrar-General. 

'Acton:  Op.  citat.,  p.  198.    Kidge :  Medical  Times  and  Gazette,  vol.  ii.,  p.  274. 
1871. 

8  St.  Bartholomew's,  St.  Thomas's,  and  the  Metropolitan  Free. 


TREATMENT. 


175 


TABLE  IX. 
Statistics  of  Orchitis. 


_«• 

i 

1 

a 

.5 

1852. 
Week  ending 

d 

Bartholomew 
Hospital. 

Thomas's  H 
pital. 

U 

\a.l  Number. 

Hean  highesi 
emperature  i 
the  Week. 

Mean  lowest 
emperature  i 
the  Week. 

General  Direction 
of  Wind. 

o.  of  Rainfall 
inches. 

rt 

. 

• 

1u 

o 

pH 

H 

3 

Q 

w 

8 

^ 

H 

CO 

f 

4 

2 

> 

5 

I 

Jan.  10  ...- 

8 

I 

-     8 

46*0 

347 

S.W. 

0'12 

9 

2 

10 

2 

„ 

' 

12 

2 

I 

> 

Jan.  17  ...  • 

13 

14 

I 

2 

I 

-     8 

Sr8 

4r5 

s.w. 

I-76 

15 

I 

Jan.  24  ... 

21 

| 

... 

i 

45'2 

35'9 

S.W. 

°'44 

26 

I 

Jan.  '31  ... 

27 
28 

I 
I 

I 

... 

-    5 

49-0 

36-1 

S.W. 

0'54 

31 

I 

... 

2 

2 

Feb.  7    ... 

3 

5 

I 

I 

-    5 

53-2 

41-9 

W.S.W. 

0-32 

7 

I 

9 

3 

1 

Feb.  14... 

10 

12 

2 
2 

I 

•  10 

46-4 

33'3 

N.  and  S.,  S.E. 

O'22 

13 

I 

Feb.  3i  ... 

16 
19 

I 

I 
2 

4 

46-1, 

33-8 

W.  and  N. 

0-03 

Feb.  28... 

23 
26 

2 

2 

I 

5 

45-i 

327 

N.E. 

O'i6 

i 

I 

March  6...- 

3 

I 

.., 

-    3 

45-6 

283 

N,  and  E. 

0'02 

6 

I 

8 

I 

March  13  - 

10 
12 

2 
I 

I 

I 

•     9 

49'9 

32-3 

N.E. 

O'OO 

13 

I 

I 

I 

16 

I 

March  20  - 

17 
18 

3 

•     4 

487 

33*2 

N.E. 

O'OO 

20 

.  .  . 

,., 

22 

i 

23 

I 

March  27  - 

24 

i 

I 

..  «  « 

6 

$6-4 

32-4 

S.E.  and  N.E. 

O'OO 

2S 

i 

- 

26 

i 

.,. 

176 


ON   GONORRHOEA. 


Week  ending 

V 

St,  Bartholomew's 
Hospital. 

St.  Thomas's  Hos- 
pital. 

§ 

1i 

V 

V 

S 

Total  Number. 

Mean  highest 
Temperature  in 
the  Week. 

Mean  lowest 
Temperature  ia 
the  Week. 

General  Direction 
of  Wind. 

Sum  of  Rainfall  in 
inches. 

April'3  ...  j 

I 

2 

... 

3 
i 

... 

4 

527 

•34-5 

E,  N.,  E. 

0*12 

April  10... 

8 

2 

••» 

..» 

2 

56-3 

33'3 

E.  and  N.E. 

O'OO 

April  17...  j 

12 
14 

3 

... 

1 

I 

5 

60-0 

33'4 

E.  and  N.E. 

O'OO 

April  24...  -j 

19 
21 

23 

3 

i 

I 

•  >  « 

> 

57*9 

34'9 

N.E.  and  E. 

O'OO 

May  i    ... 

26 
29 

2 

I 

... 

3 

60-8 

38-0 

(i) 

0*52 

May  8   ...J 

4 
6 
8 

2 
I 

I 

•"* 

• 

60-  1 

35'° 

N.E.  and  S.W. 

croo 

May  15  ...  j 

II 
13 

... 

I 

I 

•'• 

i  • 

63-6 

457 

S.W. 

0-30 

16 

... 

I 

... 

May  22  ...  • 

17 
19 

I 
I 

I 

.   I 

•    7 

66-3 

47*3 

(3) 

0-84 

21 

... 

2 

24 

... 

I 

I 

May  29  ... 

25 

28 

2 

I 

I 

8 

587 

46-3 

N. 

0-87 

29 

2 

... 

... 

31 

I 

... 

... 

June  S   ..  - 

I 

2 

... 

... 

5 

637 

43'4 

S.W.  and  S. 

O'20 

S 

I 

... 

I 

June  12... 

7 

I 

...- 

... 

i 

62-8 

49-6 

S.E.  and  S.W. 

2'63 

14 

™ 

I 

June  19...- 

15. 
17 

;      I 

I 

' 

66-4 

49*0 

S.W.  and  S.S.E. 

1-09 

. 

19 

I 

... 

... 

21 

I 

I 

4.. 

June  26...- 

22 

I 

... 

4 

69-5 

50-4 

S.  and  S.W. 

°'54 

\ 

24 
28 

30 

I 

I 

I 

... 

2 

(3) 
107 

52-0 

S.W. 

0*09 

July  10  ... 

5 

I 

... 

... 

I 

86-2 

57'3 

S.E. 

O'OO 

July  19  ...J 

12 
13 
15 

4 
I 
I 

... 

... 

}' 

81-9 

57'3 

N.E. 

0-27, 

(  I  )  Generally  calm  ;  most  prevalent  direction  E.  and  N. 

(  2  )  E.  and  N.  prevailing. 

(  3  )  The  correctness  of  these  entries  is  doubtful. 


TREATMENT. 


177 


„ 

. 

.5 

*> 

o 

U 

4J  .5 

c 

V 

K 

h.    . 

t! 

£  u  . 

v  w  _« 

3 

Jl 

.•"  . 

c~a 

J 

"Ss"" 

o  H  « 

.5  A 

1852. 
Week  ending 

I! 

is'P1 

E 

rt  O.  u 

Is 

General  Direction 
of  Wind. 

&\ 

J3 

V 

N 

H 

»• 

"3 

s  S  ** 

S  S" 

- 

el 

• 

o 

o 

H 

H 

3 

Q 

tn 

w 

* 

H 

OT 

July  24  ... 

19 
22 

I 
I 

i    * 

79*3 

547 

(0 

O'OI 

July  31  -I 

26 
27 
29 

3 

2 

•  .-. 

jf 

78-5 

55-6 

N.E.  and  N. 

2-04 

( 

31 

I 

... 

3 

5 

August  7 

4 

i 

I 

-     8 

74'4 

53'4 

S. 

I  '01 

5 

i 

9 

i 

August  14  - 

10 

i 

4 

70*2 

_«7 

S.W. 

4-48 

ii 

i 

I 

16 

2 

August  21  • 

18 

I 

-    5 

70-9 

56-6 

(2) 

rqi 

19 

I 

I 

August  28 

27 
28 

I 

I 

2 

75'3 

57T 

N.,  N.E.,andS.W. 

QUO 

i 

30 

I 

Sept.  4  ...-I 

2 

I 
I 

... 

-     6 

73'9 

Si-9 

S.W.  and  S.E. 

O'OO 

I 

3 

2 

I 

6 

I 

8 

2 

I 

9 

I 

•     9 

69-2 

55'9 

N. 

i  '40 

10 

2 

ii 

2 

14 

I 

I 

3 

64*5 

45-8 

(3) 

0-85 

16 

I 

20 

I 

23 

I 

I 

-     4 

64-0 

46-5 

S.W. 

o-oo 

24 

I 

... 

f 

27 

2 

I 

29 

I 

Oct.  2     ...\ 

30 

3 

... 

('i') 

•   13 

6r8 

43'4 

N.E.  and  S.W. 

i'3> 

1 

i 

... 

( 

2 

4 

I 

. 

&. 

7 

I 

\ 

5 

•? 
2 

r  8 

53'4 

41-3 

S.W.  and  N.W. 

rog 

6 

2 

J 

(  i  )  Variable ;  S.  and  W.  prevailing. 

(  2  )  Variable  ;  much  calm ;  N.  and  W.  prevailing. 

(  3  )  Calm  ;  W.  prevailing. 

(  4  )  One  of  these  is  said  to  have  occurred  from  stricture. 

12 


178 


ON    GONOKRHCEA. 


1852. 

Week  ending 

1 

St.  Bartholomew's 
Hospital.  ' 

St  Thomas's  Hos- 
pital. 

S 
.3  '3. 

¥ 

s 

Total  Number. 

Mean  highest 
Temperature  In 
the  Week. 

Mean  lowest 
Temperature  in. 
the  Week. 

General  Direction 
of  Wind. 

Sum  of  Rainfall  in 
inches. 

| 

II 

I 

... 

... 

^ 

Oct.  16  ... 

12 

15 

I 

V 

... 

4 

557 

41-2 

N.E. 

0*03 

16 

I 

... 

... 

J 

• 

18 

2 

... 

19 

I 

... 

... 

Oct.  '23  ...  • 

20 
21 

I 

4 

... 

... 

•12 

59-6 

39'9 

N.E.  and  S.W. 

0-42 

22 

2 

... 

i 

, 

23 

I 

... 

... 

. 

' 

25 

3 

... 

... 

11 

26 

2 

... 

i 

Oct.  30  ...- 

28 

3 

... 

... 

'     13 

52-0 

40-5 

S.W.  and  N.W. 

2'OI 

29 

2 

I 

... 

. 

3° 

I 

... 

. 

i 

2 

... 

... 

2 

2 

2 

Nov.  6   ... 

3 
4 

•1 

I 

... 

10? 

607 

48-0 

S.W. 

0-84 

5 

I  V 

(O 

... 

6 

I  J 

8 

I 

i 

•> 

10 

2 

... 

... 

Nov.  13...  • 

ii 

3 

... 

9 

49-2 

43'° 

S.W.  and  N.E. 

1-30 

12 

i 

... 

13 

i 

... 

... 

j 

15 

2 

... 

... 

} 

Nov.  20...* 

10 

17 

2 
3 

i 

9 

SS-o 

45-i 

S.W. 

177 

19 

i 

) 

21 

2 

... 

i.. 

~\ 

22 

I 

... 

I 

Nov.  27...- 

24 

2 

... 

8 

51-0 

40-6 

N.  and  S.W. 

1-46 

25 

I 

... 

... 

27 

I 

... 

... 

J 

f 

.29 

I 

"... 

I 

1 

3° 

i 

Dec.  4  ...^ 

i 

I 

2 

... 

r  IS 

47  -o 

37'5 

S.W. 

0-33 

3 

2 

I 

I 

I 

4 

3 

2 

j 

(  i  )  These  entries  are  uncertain  ;   the  MS.  by  my  amanuensis  not  being  very 
reliable  in  this  part. 


TREATMENT. 


179 


1852. 

Week  ending 

*j 

Bartholomew's 
Hospital. 

Thomas's  Hos- 
pital. 

tropolitan  Free 
Hospital. 

:al  Number. 

Vlean  highest 
emperature  in 
the  Week. 

Mean  lowest 
'emperature  in 
the  Week. 

General  Direction 
of  Wind. 

a  of  Rainfall  in 
inches. 

5 

• 

^ 

V 

o 

"H 

H 

§ 

A 

oi 

to 

2 

H 

CO 

5 

6 

6 

... 

I 

Dec,  -i  i...- 

7 

2 

... 

I 

17 

S3'i 

46^ 

s.w. 

o'6i 

8 

3 

... 

ii 

3 

I 

... 

14 

3 

I 

... 

1 

15 

I 

Dec.  18...- 

16 

I 

... 

-     8 

53'i 

43'8 

S.  and  S.W. 

0'59 

17 

I 

18 

i 

... 

j 

(i) 

Dec.  25  ... 

20 
21 

i 

I 

2 

Si'9 

40*5 

(2) 

o'os 

1853- 

27 

I 

>! 

28 

2 

... 

Jan.  i    ...- 

29 

30 

2 
I 

•     8 

517 

41-8 

S.W. 

0'43 

31 

I 

... 

I 

I 

... 

... 

. 

' 

2 

I 

... 

• 

3 

3 

Jan£S  *.. 

4 

3 
3 

I 

I 

•  J4 

51-2 

39'i 

S,W, 

071 

6 

,.. 

I 

k 

.  7 

i 

... 

. 

' 

10 

i 

• 

12 

i 

.1. 

I 

Jan.  15  ...- 

13 

I 

2 

13 

50-5 

39'S 

S.W. 

o'4S 

14 

... 

I 

... 

. 

15 

2 

4 

... 

. 

17 

2 

... 

IS 

I 

i 

Jan.  22  ... 

19 

2 

•     8 

47-2 

36-1 

N.W.-andS.W 

o'59 

20 

I 

. 

22 

I 

.  .  . 

t 

24 

2 

... 

25 

i 

Jan.  29  ...- 

26 
27 

2 

i 

•     8 

4»7 

34'6 

N.E. 

0-007 

28 

I 

• 

29 

i 

... 

(  I  )  For  these  last  five  weeks,  no  electricity  shown  by  any  instruments.  For  the 
next  three  weeks  no  record  given,  the  electrical  apparatus  having  been  injured  by  a 
gale,  which  I  regret,  as  the  sudden  rise  might  have  been  compared  with  the  results. 

(  2  )  Much  calm ;  S.  and  W.  prevailing. 


180 


ON    GONOKEHCEA. 


1853. 

Weekending 

1 

St.  Bartholomew's 
Hospital. 

St.  Thomas's  Hos- 
pital. 

E 

1 

V 

S 

Total  Number. 

Mean  highest 
Temperature  in 
the  Week. 

Mean  lowest 
Temperature  in 
the  Week. 

General  Direction 
of  Wind. 

Sum  of  Rainfall  in 
inches. 

Feb.  5  ...- 

2 

4 

2 

I 
I 

I 

... 

, 

-12-3 

32-0 

(I) 

O'2O 

5 

I 

I 

7 

I 

' 

8 

2 

... 

... 

Feb.  12 

j9 

3 

... 

... 

9 

39'5 

3rS 

S.E.  and  N.N.E. 

O'O6 

ii 

i 

I 

12 

i 

14 

2 

I 

IS 

2 

I 

I 

Feb.  19... 

16 

2 

... 

«J 

3S'S 

26-1 

N. 

0'33 

18 

I 

2 

... 

19 

I 

... 

21 

I 

I 

2 

22 

2 

... 

Feb.  26...- 

23 

24 

I 

I 

I 

17 

39*8 

28-0 

•N. 

0-39 

25 

3 

4 

... 

26 

I 

... 

28 

2 

... 

... 

I 

I 

I 

... 

March  5...- 

2 
3 

I 
I 

I 

2 

ii 

42-8 

297 

(2) 

0-68 

4 

I 

... 

.... 

(3) 

5 

I 

... 

... 

8 

2 

^. 

... 

' 

March  12  - 

9 

... 

... 

1 

4 

53-8 

37'i 

(4) 

0-17 

10 

...• 

I 

..-. 

13 

2 

»M 

.-.  * 

• 

14 

... 

I 

... 

March  19  • 

IS 

17 

3 

I 

... 

9 

447 

3ix> 

NE. 

0-51 

18 

I 

... 

19 

i 

... 

... 

, 

21 

I 

' 

March  26  • 

22 

i 

I 

I 

6 

417 

26*0 

N.E. 

O'lO 

26 

'" 

2 

... 

• 

(  I  )  Much  calm :  N.  and  E.  prevailing 
(  2  )  Variable ;  from  all  points  of  the  compass. 

{  3  )  Electricity  was  only  shown  once  this  week  and  once  the  week  before, 
jreek  before  that  there  was  none. 
(  4  )  Almost  always  calm. 


The 


TREATMENT. 


181 


ji> 

.  ( 

V 

.S1 

m 

0 

4~l      ^* 

e 

i 

E 

£   . 

ij 

s  '«  - 

"    0      . 

"3 

E  — 

• 

o  5 

i?1      . 

a  S 

£ 

tc  ™  ^ 

&    3    0 

"c  * 

fH&3- 

Week  ending 

V 

1'S. 

t« 
«a 

03 

S"5 

j-s. 

H 

•-'5. 

F 

e 

3 
K 

1 

§  !« 

"  £•£ 

c  u-5 

I  II 

General  Direction* 
of  Wind. 

II 

u.  n 
o1" 

g 

I 

</: 

M 

in 

s 

O 

H 

to 

28 

3 

1 

29 

I 

2 

30 
31 

I 

I 

I 

13 

53'5 

34-3 

Variable 

0-44 

I 

.., 

I 

2 

2 

I 

... 

) 

• 

4 

I 

2 

" 

5 

I 

April  9  ...- 

6 

I 

... 

9 

55'9 

43-3 

W. 

0-44 

7 

2 

I 

... 

9 

I 

... 

{ 

ii 

3 

3 

1 

12 

i 

April  16...  -{ 

13 

ii 

52'9 

38-0 

N.E^and  N.W; 

O'O2 

14 

i 

2 

I 

16 

I 

... 

{ 

18 

'  4 

I 

... 

(  O 

19 

I 

V         / 

April  23...^ 

20 

I 

... 

ii 

54'5 

41-3 

Variable 

0-90 

21 

2 

... 

... 

I 

23 

2 

... 

•     April  30...- 

25 
27 
28 

I 
I 

I 

4 

(2) 
517 

36-0 

Variable 

1-32 

29 

I 

... 

2 

I 

... 

I 

May  7    ...- 

4 

5 

4 

I 

I 

9 

57-2 

41-4 

"Eys:E..  and  N.E. 

0-84 

6 

... 

I 

9 

2 

... 

...  ' 

ii 

I 

I 

May  14...- 

12 

I 

I 

... 

8 

56-0 

37'i 

Variable 

0'37 

13 

1 

. 

14 

I 

... 

, 

16 

3 

... 

May  21  ...- 

19 

i 

2 

... 

-    8 

67-1 

43'8 

WL 

O'OO 

20 

2 

... 

... 

' 

23 

I 

'  I 

... 

24 

I 

I 

May  28  ...  - 

2 

9 

72-6 

46-4 

NX 

0-13 

26 

I 

I 

... 

• 

28 

I 

• 

(  I  )  Up  to  this  time,  ever  since  the  last  note,  the  electrical  apparatus  was  under* 
going  repair. 

(  2  )  Electricity  strong,  negative  and  positive^  during  four-,  days. 


182 


ON    GONOBRH(EA. 


• 

o 

• 

e 

.3 

1853. 

Week  ending 

i 

Bartholome: 
Hospital. 

Thomas's  H 
pitaL 

ii 

1L§ 

al  Number. 

Mean  highe'sl 
emperaturc  i 
the  Week. 

Mean  lowest 
emperature  i 
the  Week. 

General  Direction' 
of  Wind. 

n  of  Rainfall 
inches. 

cd 

• 

«j 

*J 

"H 

H 

3 

Q 

w 

OT 

H 

V} 

31 

J 

i 

N 

June  4   ...- 

2 

3 

2 
2 

.. 

-     8 

62-1 

46'! 

N. 

0-42 

4 

I 

i 

6 

2 

I 

7 

I 

i 

June  II  ... 

8 

I 

I 

... 

12 

73'3 

49'2 

S.W.  and  S.E. 

0-24 

9 

I 

__. 

10 

I 

3 

... 

14 

2 

i 

... 

June  18...- 

16 

2 

-    7 

69'3 

51*2 

N.  and  S.W. 

1-30 

18 

2 



20 

... 

2 

i 

June  25...- 

23 

24 

3 
i 

2 

... 

-  ii 

677 

48-9 

Variable 

0-55 

25 

i 

I 

.... 

27 

... 

2 

28 

3(1) 

... 

Julys    ...- 

29 

30 

2 

2, 

I 

:::' 

.16 

68-3 

53-2 

S.W. 

0-89 

I 

3 

2 

(2) 

2 

I 

... 

4 

4 

2 

'i 

5 

I 

I 

July  9    ...- 

6 
7 

i 

2 
3 

I 

22 

75*2 

55-6 

S.W.  and  S. 

0-88 

8 

... 

2 

9 

2 

I 

I 

ii 

I 

I 

July  16  ...- 

12 
15 

I 

2 

•" 

•    9 

68-3 

52*2 

S.W. 

3-H 

16 

4 



• 

18 

I 

3 

I  V 

19 

I 

,2 

I 

July  23...- 

20 

21 

i 
i 

-- 

I 

14 

69-6 

53-2 

S.W. 

0-29 

22 

... 

I 

(3) 

23 

i 

-  — 

... 

(  I  )  One  of  these  from  stricture. 

(  2  )  Positive  and  negative  electricity,  with  strong  tension,  has  been  shown  during 
the  week,  at  times  when  rain  fell.  The  next  week  the  electrometer,  as  was  commonly 
the  case  of  late,  was  out  of  repair  till  the  last  day  (9th),  when  it  showed  negative  and 
very  active. 

(  3  )  No  electricity  for  three  days;  three  days  positive  and  weak;  one  day  negative 
And  active. 


TREATMENT. 


183 


i 

a 

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(  2  )  Principally  E. 

(  3  )  Both  this  week  and  last  the  electricity  was  much  more  active,  both  positive 
and  negative.     Tension  strong  or  moderate. 

(  4  )  These  are  called  "  swelled  testicle  "  in  the  book. 

)  Electricity  always  positive  ;  tension  mostly  moderate,  sometimes  very  strong. 

)  Much  calm  ;  E.  rather  prevailing. 


184 


ON    GONOKRHCEA. 


..1853. 
\7sek  ending 

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(  I  )  With  the  exception  of  a  small  amount  of  positive  electricity  at  3  a,m.  on 
Saturday,  none  was  shown  throughout  the  week. 

(  2  )  No  electricity  was  shown  during  the  preceding  week,  or  during  the  first  days 
of  this  week,  after  which  the  apparatus  is  again  reported  "  under  repair." 

(  3  )  During  four  days  of  this  week,  and  three  days  of  the  week  preceding,  the 
electrical  apparatus  was  out  of  repair.  On  every  other  day,  and  during  the  whole  of 
the  week  ending  November  12,  it  showed  positive  electricity,  the  tension  being  strong 
towards  the  close  of  this  time. 


TKEATMENT. 


185 


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(  I  )  Much  calm ;  E.  prevailing. 

(  2  )  Positive  and  tension  very  strong  during  last  three  weeks;  declines  this  week. 

(  3  )  Electricity  positive  and  strong. 


186  ON    GONOREHCEA. 

The  entire  number  of  cases  then,  obtained  in  1852  was  309  ;  and  for 
1853,  535.  On  consulting  the  table  for  1852,  it  will  be  found  that  there 
was  a  slight  but  steady  rise  up  to  the  end  of  the  third  quarter  of  the  year, 
when  the  proportion  increased  so  rapidly  that  in  October  there  were  nearly 
twice  as  many  cases  as  in  the  highest  of  the  preceding  months.  The 
greatest  number  in  any  one  week  occurred  in  the  second  week  of  Decem- 
ber, and  the  next  greatest  number  in  the  first  week  of  the  same  month. 
The  minimum  of  cases  ensued  in  June,  April,  July,  and  August. 

In  1853  the  maximum  was  attained  in  July — which,  it  will  be  seen, 
yields  70  cases  ;  next  to  this  stand  October,  giving  52,  and  January,  which 
gives  51.  The  lowest  number  is  met  with  in  March,  August,  May, 
September,  and  June,  which  possess  an  average  of  less  than  34  ;  while 
January,  April,  and  November  show  about  one-third  as  much  again.  Along 
with  this  table  the  reader  will  find  one  of  the  weather  for  those  two  years, 
and  will  thus  have  an  opportunity  of  forming  his  opinion  from  facts. 

Whether  changes  in  the  electric  state  of  the  air  have  anything  to  do 
with  the  presence  of  orchitis,  is  more  than  I  know.  .  I  certainly  suspect 
they  have,  far  more  so  at  any  rate  than  heat  or  cold,  the  influence  of  which 
in  producing  disorders  is,  to  my  thinking,  quite  overrated.  In  the  present 
instance  it  will  be  seen  that,  during  the  greater  part  of  the  first  eight 
months  of  1852,  the  number  of  cases  is  exceedingly  small.  Now  during 
far  the  greater  part  of  this  time,  week  after  week,  the  electricity  is  reported 
as  positive  with  moderate  tension,  the  number  of  days  on  which  negative 
electricity  was  shown  being  very  few  indeed.  In  the  second  week  of  Sep- 
tember, the  number  of  cases  is  greater  than  had  been  noted  for  a  long 
time,  and  the  electricity  is  reported  negative  and  very  active.  Immediately 
after  this  there  is  a  fall  in  the  number,  and  the  electricity  is  again  marked 
positive  and  active.  Then,  after  a  slight  wavering,  a  great  increase  in  the 
number  of  cases  will  be  found  for  many  weeks  after,  and  from  this  time 
till  Christmas  the  reports  give  "no  electricity  at  all."  But  here,  unfor- 
tunately, the  clue  of  the  investigation  is  lost,  for  the  electrical  apparatus 
was  so  damaged  by  a  gale  of  wind  that  a  long  time  elapsed  before  it 
could  be  set  to  work  again. 

An  opinion  that  gonorrhoea  is  more  liable  to  relapse  at  certain  times  of 
the  year  than  at  others,  has  been  advanced  by  some  authors ;  M.  Robert 
says  that  the  spring  seems  greatly  to  favor  relapses,  and  I  have  fancied  I 
detected  something  of  the  tendency  myself  during  the  prevalence  of  cold, 
dry,  east  winds.  The  question,  however,  is  difficult  to  settle  till  we  have 
much  better  data.  If  the  mere  revolution  of  seasons  influenced  the  num- 
ber of  cases,  we  might  expect  a  regularly  recurring  increase  in  spring,  and 
of  this  I  have  not  as  yet  seen  any  proof  worth  notice. 

We  do  not  possess  such  full  information  as  might  be  wished  with  respect 
to  the  proportion  of  gonorrhoea  patients  attacked  by  orchitis.  M.  Le  Fort 
gives  it  at  129  to  914,  the  latter  being  all  cases  of  first  infections,  but  this 


TREATMENT.  187 

is  very  much  higher  than  anything  I  have  seen.  Castelnau  found 1  the 
proportion  to  be  as  high  as  1  in  4£,  or  265  in  1,172,  while  Gaussail  computed 
the  relative  numbers  at  1  to  10,  and  Fournier  at  1  to  8  or  9  ;  figures  much 
more  in  accordance  with  my  own  observations  than  those  of  the  two  first 
authors. 

From  a  table  by  M.  Castelnau 2  of  239  cases,  we  learn  that  the  affection 
appeared  in  the  1st  week  of  the  gonorrhcea  16  times,  in  the  2d  34,  in  the 
3d  24,  in  the  4th  39,  in  the  5th  54,  in  the  6th  and  later  72  ;  whereas 
Fournier  in  206  cases  found  none  in  the  1st  week  and  only  two  on  the  8th 
and  9th  day. 

M.  Despres  holds 3  that  relapsing  orchitis  is  due  to  retention  of  the 
semen  in  the  testicles.  The  cause  of  this  does  not  always  exist  at  the 
same  point,  but  it  is  more  than  probable  that  swelling  of  the  mucous  mem- 
brane of  the  ejaculatory  duct  or  of  the  vas  deferens,  or  even  peripheral 
swelling  of  the  prostate  or  of  the  mucous  membrane  of  the  urethra,  may 
induce  the  retention  of  the  seminal  fluid.  As  suppuration  is  so  rare  in 
orchitis,  the  affection  might  very  well  be  called  spermatic  engorgement  of 
the  testicle,  just  as  retention  of  the  milk  in  the  mamma  is  called  lacteal 
engorgement,  a  suggestion  of  doubtful  utility  till  we  feel  quite  assured 
that  we  have  mastered  the  pathology  of  the  disease.  Orchitis  of  this  kind 
ensues  after  cutting  for  the  stone.  With  proper  deference  to  M.  Despres, 
it  seems  to  me  that  the  action  is  purely  reflex  ;  but  I  agree  with  him  in 
this  much,  that  I  think  a  great  deal  of  the  morbid  action  we  are  called 
upon  to  meet  begins  with  spasm,  a  doctrine  long  ago  laid  down  by  myself 
in  earlier  editions  of  this  work. 

Prognosis. — Always  favorable  when  the  affection  is  taken  in  time  and 
the  patient  endowed  with  reasonable  prudence  and  perseverance  ;  qualities, 
however,  not  unfrequently  wanting.  Extensive  effusion  into  the  vaginal 
sac  and  hardening  of  the  cauda  epididymis  may  prove  very  obstinate, 
especially  if  not  duly  attended  to,  but  all  their  more  serious  results  can 
always  be  removed. 

Results. — Among  these  are  enumerated  death,  neuralgia  of  the  organ 
as  also  of  the  pudenda!  plexus,4  intense  tenderness,  setting  up  a  fixed 
desire  to  have  the  gland  removed,5  tuberculous  deposit,  cancer,6  abscess, 
effusion  more  or  less  extensive  into  the  vaginal  sac,  suppuration  in  this 
cavity,7  sphacelus  of  the  testicle  from  inflammation  attacking  essentially 
the  body  of  this  organ/  destruction  of  the  seminiferous  tubes,9  wasting  of 

1  Op.  citat.  p.  197.  2  Ibid.,  p.  199,  3  Gazette  des  Hopitaux,  p.  965.    1878. 

4  Zeissl :  Wiener  medizinische  Zeitung-,  1870.     Quoted  in  the  Archiv  fur  Derma- 
tologie,  B.  iii.,  S.  413. 

5  Lectures  of  Sir  Astley  Cooper,  vol.  ii.,  p.  155.     1825. 
"Robert:  Op.  citat.,  p.  221;  Phillips:  Op.  citat,  p.  120. 
1  Johnson:  Op.  citat.,  p.  193. 

"Nouveau  Dictioiinaire  de  Medecine,  tome  v.,  p.  222.     1866. 

9  The  Structure  and  Diseases  of  the  Testis,  part  ii. ,  p.  23.     By  Sir  Astley  Cooper. 


188  ON    GONORRHCEA. 

the  testis,  and  impotence.  Only  two  authors,  I  think,  mention  death  as 
a  consequence,  so  that  it  must  be  very  rare.  I  quite  concur  in  what  Roki- 
tansky  says  as  to  neuralgia  being  a  rare  result.  I  have  often  seen  a  good 
deal  of  weary  aching  and  pain  in  the  testicles  follow  gonorrhoea,  and  still 
more  frequently  if  complicated  by  a  sudden  outbreak  of  spermatorrhoea, 
but  I  never  saw  orchitis  end  in  what  I  should  call  genuine  neuralgia  of  the 
testis.  The  connection  of  the  two  is,  indeed,  in  no  way  established  :  and 
as  to  carcinoma,  we  may  almost  class  it  with  the  prejudices  of  a  bygone 
age.  If  such  an  occurrence  had  been  at  all  common,  we  ought  to  have 
had  some  proofs  of  it  before  now.  The  absorbent  vessels  of  the  penis  and 
scrotum,  we  are  told,  may  become  inflamed  on  such  occasions ;  I  have  not 
seen  this.  Of  sphacelus  of  the  testicle  I  can  say  nothing  from  personal 
experience,  having  never  seen  such  a  termination  of  the  disorder,  though, 
like  others,  I  have  had  to  treat  the  latter.  According  to  M.  Fournier,  who 
gives  a  very  clear  account  of  it,  the  unfortunate  issue  of  the  case  is  marked 
by  sudden  cessation  of  the  "  atrocious  "  pain  which  accompanies  its  earlier 
stages.  M.  Mauriac,  in  a  series  of  exhaustive  papers,1  gives  a  very  full 
account  of  the  nervous  pains  set  up  by  orchitis  in  the  hypogastrium,  groin, 
posterior  crural  region,  waist,  lower  and  front  part  of  belly,  sacro-iliac 
articulations,  thighs,  loins,  etc. ;  more  perhaps  to  be  considered  as  compli- 
cations than  results. 

The  real  results  to  dread  are  obliteration  of  larger  or  smaller  portions 
of  the  seminal  tubes,  owing  to  deposit  of  fibrine  ;  effusion  of  serum  ; 
hardening  of  the  epipidymis,  generally  seated  in  the  cauda,  where  it  forms 
a  small  knot ;  wasting  of  the  testicle,  and  suppuration  in  it  or  the  scro- 
tum. 

That  hardening  of  the  epididymis,  especially  if  it  affect  both  sides,  may 
lead  to  impotence,  is  a  general  and  well-founded  opinion.  Mr.  Curling 
mentions  2  several  cases  of  absence  of  semen  after  orchitis  of  both  testicles, 
and  I  have  seen  the  same  thing.  Suppuration  of  the  testicle  and  deposit 
of  fibrine  among  the  convolutions  of  the  epididymis  may  go  on  to  a  con- 
siderable extent  without  interfering  with  the  functions  of  the  gland. 

There  can  be  little  doubt  that  authors  are  right  in  assuming  that  im- 
potence does  not  follow  so  long  as  the  disease  is  only  confined  to  one 
gland  or  limited  to  mere  hardening.  But  this  hardening  is  also  apt  to  be 
accompanied  or  followed  by  contraction  of  the  sole  channel  for  the  expul- 
sion of  the  semen.  Mr.  Holmes  Coote  told  me  that  he  had  often  found 
induration  accompanied  by  obstruction  of  the  epididymis.  M.  Gosselin's 
observations,  and  those  of  M  Marce  and  M.  Charles  Robin,  confirm  this 
view,  and  my  own  are  quite  in  accordance  with  it.  Indeed  when  a  delicate 
mucous  membrane  is  converted  into  a  rigid  contracted  tube,  we  can  hardly 
expect  that  it  will  execute  its  normal  functions.  M.  Robert,  however,  has 

1  Gazette  M6dicale,  p.  381,  etc.     1869. 

9  On  the  Diseases  of  the  Testis,  p.  439.     1866. 


TKEATMENT.  189 

seen,1  at  the  expiration  of  five  or  six  months,  a  return  of  the  animalculse 
after  double  epididymitis,  at  first  in  small  numbers,  but  subsequently  as 
numerous  as  if  there  had  never  been  a  pathological  change  in  the  organs. 

Treatment  usually  Adopted. — We  are  generally  recommended  to  treat 
this  affection  by  antiphlogistics.  The  plan  of  combating  it  by  emetics,  so 
greatly  patronized  by  many  of  the  older  writers,  has,  generally  speaking, 
died  a  natural  death,  though  here  and  there,  evidently  enough,  its  ghost 
still  lingers  ;  a  relic  of  faith  in  this  treatment  may  also  be  traced  in  the 
nauseating  doses  of  antimony  prescribed  by  some  writers.  The  recom- 
mendation to  use  antiphlogistic  means  is  only  consistent  with  the  theory 
of  those  who  consider  that  inflammation  is  not  to  be  exercised  but  by 
measures  which  reduce  the  patient's  health ;  they  who  hold  such  a  view 
ought  to  stand  by  the  axiom  that  we  can  only  banish  the  intrusive  demon 
secundum  artem.  But  I  am  inclined  to  suspect  that  the  system  now  lives 
only  by  sufferance,  and  that  no  one  of  its  supporters,  if  put  to  the  test, 
could  prove  it  to  be  called  for.  Bleeding,  considered  by  M.  Eobert  indis- 
pensable when  the  body  of  the  testicle  is  affected,  owes  its  tenure  of 
•existence,  if  indeed  it  exist  at  all,  to  a  long  and  most  respectable  descent, 
to  ancestral  prestige  in  fact ;  but  I  suppose  we  may  look  upon  it  as  gone 
for  good,  whatever  affection  of  the  organ  may  seem  to  call  for  it.  Leeches, 
calomel,  antimony,  salines,  etc.,  often  leave  the  pain  unrelieved  for  eight 
or  ten  days,  and  so  long  as  this  lasts  the  inflammation  is  not  subdued. 
Still  less  can  we  assume  that  it  is  even  quelled  by  these  means,  seeing  that 
if  the  patient  remain  in  bed  and  restrict  himself  in  respect  to  diet  he  will 
be  cured  just  as  quickly.  Leeches  indeed  can  only  diminish  to  a  fractional 
extent  the  quantity  of  blood  driven  toward  any  inflamed  part,  whereas  the 
object  of  the  surgeon  should  be,  not  to  abstract  blood,  but  to  check  the  action 
which  impels  it  in  an  abnormal  direction.  The  congestion  of  this  fluid  offers 
a  check  to  the  process  ;  by  relieving  this  arrest  we  set  it  going  again  plena 
rivo. 

Mr.  Judd  narrates 3  a  case  of  orchitis  in  which  twenty  leeches  were  ap- 
plied to  the  testicle,  with  the  effect  of  removing  the  pain.  The  day  after 
this  is  stated,  we  find  that  the  gland  is  larger,  more  tender  and  reinflaming, 
and  the  day  after  this  again,  we  .are  told  that  the  patient  is  still  suffering 
from  a  good  deal  of  sweUing  and  pain  in  the  part,  "  although  the  leech- 
bites  bled  until  he  fainted  ! "  Again,  M.  Salleron  gives 3  one  where  the 
patient  was  bled  freely,  and  where,  two  days  after,  the  pain  was  worse  than 
ever.  Thirty  leeches  were  then  applied,  and  then  thirty  more,  without  any 
good  being  affected.  Mr.  Johnson,  who  used  to  lay  the  patient  up,  order 
leeches,  and  give  calomel,  opium,  and  antimony,  occasionally  adding  salines 
and  colchicum,  says,  "  It  is  a  very  severe  attack  indeed  which  in  less  than  a 


1  Op.  citat.,  p.  233.  "Op.  citat.,  p.  52. 

8  Archives  Generates  de  Medecine,  tome  ii.,  p.  165.     1870. 


190  OX    GONOKRHCEA. 

week  of  this  treatment,  has  not  lapsed  into  a  milder  form."  And  again  :  "I 
believe  that  the  average  duration  of  an  acute  attack,  treated  in  the  manner 
I  have  recommended,  is  between  two  and  three  weeks.  "When  relapses 
take  place  they  may  protract  it  to  a  month,  or  six  weeks,  or  longer."  As  to 
the  inconveniences  said  to  result  occasionally  from  the  use  of  leeches,  such 
as  erysipelas,  they  would  not  deter  me  from  employing  a  remedy  from 
which  I  could  expect  aid.  I  believe  them  to  be  imaginary,  and  I  am  com- 
pelled to  state  that  the  diametrically  opposite  evidence  on  this  point  in 
England  leads  me,  and  indeed  would  lead  any  one  else,  to  surmise  that 
conjecture,  respect  for  authority,  and  conviction  have  had  more  to  do  with 
the  matter  than  observation  and  analysis. 

With  regard  to  some  other  parts  of  the  treatment,  such  as  puncture  of 
the  scrota!  veins,  what  little  I  can  make  out  is  that  they  are  entirely  use- 
less, although  not  harmless,  as  one  patient  died  from  a  vein  in  the  scrotum 
being  opened  ;  a  catastrophe  which  perhaps  induced  the  surgeon  to  alter 
his  views  on  the  subject.1  Puncturing  the  scrotum  on  M.  Velpeau's 
method,  whatever  it  may  be,  for  he  merely  speaks "  of  it  as  "puncture  of 
the  tumor,"  seems  to  have  been  almost  as  unfortunate.  M.  Demarquay 
saw  wasting  of  the  testicle  in  three  cases,  and,  including  one  of  orchitis 
from  stricture,  four  cases  where  it  was  trusted  to,  but  in  one  of  these  if 
not  in  all,  the  tunica  albuginea  was  opened ;  and  M.  Montanier  noticed 
serious  bleeding  after  it,  although  the  incisions  were  mere  pricks  (mouche- 
tures).3  My  experience  of  tartar  emetic,  calomel,  and  other  items  of  anti- 
phlogistic treatment,  is  not  more  favorable,  or,  in  plain  terms,  I  believe 
them  to  be  perfectly  useless.  Tartar  emetic  is  a  most  potent  remedy  in 
controlling  inflammation  of  the  cellular  tissue,  but  has  little  influence  over 
those  of  mucous  membranes,  and  in  orchitis  I  have  generally  found  that  it 
produced  no  change  whatever.  It  occasionally  checks  the  formation  of 
abscess  in  the  scrotum,  but  I  am  not  aware  of  any  other  good  that  results 
from  using  it. 

I  suppose  we  or  our  descendants  will  some  day  be  treated  to  a  dissolv- 
ing view  of  those  doctrines ;  but  in  the  meantime,  as  arguments  will  never 
work  conviction,  I  will  take  the  liberty  of  putting  the  rather  awkward 
question — whether  any  of  those  who  recommend  leeches,  etc.,  have  ever 
taken  the  pains  to  ascertain  if  there  are  justifiable  grounds  for  putting  pa- 
tients to  such  expense  and  weakening  their  health,  for  these  are  two  almost 
unfailing  results  of  antiphlogistic  treatment.  Except  Mr.  Curling,  all 
those  authors  who  fix  a  time  at  all,  give  a  week  as  necessary  to  subdue  the 
more  severe  symptoms  of  orchitis,  and  thirty  or  thirty-five  days  as  the  re- 
quisite period  for  a  cure.  Now  as  any  case  of  orchitis  will  get  well  as  fast  as 
this  if  the  patient  only  remain  in  bed,  it  becomes  more  than  doubtful 

1  Johnson  :  Op.  citat. ,  p.  204. 

2  Leqons  orales  de  Clinique  chirurgicale,  tome  Hi.,  p.  461.     1841. 

3  Bulletin  de  Therapeutique,  p.  550.     1858. 


TREATMENT.  191 

whether  the  treatment  recommended  on  such  respectable  authority  really 
has  the  slightest  influence  over  the  complaint. 

Punctufc  of  the  Tunica  albuginea. — Mr.  Henry  Smith '  incises  the  tunica 
albuginea  in  severe  cases  of  orchitis,  for  which  variety  principally  he  re- 
serves the  operation.  He  makes  a  deep  and  free  incision  through  the 
tunic,  with  the  effect  of  letting  out  several  drachms  of  blood  and  serum. 
Nothing  else  is  done  beyond  prescribing  a  little  "  white  mixture"  (a  saline 
aperient,  I  presume,  containing  magnesia)  and  the  ordinary  lead  lotion  of 
the  hospital. 

Mr.  Smith  describes  the  effect  as  highly  satisfactory.  The  relief  to  the 
pain  is  so  decided  that  the  patient  feels  it  has  given  way  before  he  leaves 
the  room,  and  the  change  for  the  better  which  takes  place  within  the  first 
forty-eight  hours  is  so  great  as  to  attract  general  notice.  This  he  justly 
attributes,  not  to  the  loss  of  blood,  but  to  the  removal  of  the  constriction 
exerted  by  the  fibrous  envelope.  He  has  never  seen  the  operation  followed 
by  any  disagreeable  symptoms  but  twice.  In  one  case,  puncture  of  the 
testicle  in  a  middle-aged  man  brought  on  rapid  effusion  of  serum  into  the 
tunica  vaginalis ;  but  this  was  speedily  relieved.  In  the  other  case 
the  incision  was  made  much  deeper  than  necessary,  the  point  of  the 
knife  being  carried  nearly  to  the  back  of  the  organ.  The  only  results, 
however,  were  a  little  faintness  and  the  loss  of  about  ten  ounces  of 
blood.  The  relief  given  in  this  case  was  more  speedy  and  effectual  than 
usual. 

The  practice  has  been  long  in  vogue  in  Paris  ;  it  was  recommended  by 
Jean  Louis  Petit,  was  extensively  adopted  by  the  late  M.  Vidal  de  Cassis, 
who  punctured  to  the  extent  of  a  centimetre  and  a  half,  and  received  the 
high  sanction  of  M.  Eicord ;  Pirogoff,  too,  Mr.  Smith  tells  us  in  a  later 
communication,  punctured  as  far  back  as  1852.  He  adds  that  in  the  prac- 
tice which  comes  under  his  cognizance  swelled  testicle  is  treated  in  the 
most  heroic  way,  all  the  barbarities  of  the  old  school  being  combined  with 
the  worst  features  of  modern  treatment.  Emetics,  purgatives,  leeches, 
strapping,  are  still  in  full  play.  Such,  at  any  rate,  is  the  picture  drawn  by 
one  of  the  surgeons  to  the  hospital  where  all  this  kind  of  thing  was  being 
daily  enacted  at  the  date  of  Mr.  Smith's  communication,  and  it  must  be 
admitted  that  it  does  not  give  us  a  very  favorable  idea  of  the  practice  at 
the  sources  from  whence  alone  we  ought  to  derive  our  inspirations. 

Mr.  Smith's  assertions  were  openly  challenged  by  Mr.  Holmes,  and  a 
squabble  ensued  not  at  all  calculated  to  produce  a  favorable  impression 
as  to  the  mode  in  which  scientific  discussions  are  conducted  in  some  of 
our  English  medical  journals,  startling  assertions  of  success  being  met  by 
something  like  flat  denial ;  the  value  of  an  operation  contested,  not  so 
much  on  the  evidence  of  trials  and  experiments  as  on  that  of  authority  and 

1  Lancet,  vol.  ii.,  p.  149.     1864 


192  ON    GONORRHCEA. 

possibility ;  and  finally  both  disputants,  though  perhaps  with  their  own 
convictions  a  Little  modified,  claiming  a  complete  victory. 

Mr.  Smith  says  that  he  has  performed  the  operation  about  %,  thousand 
times,  reserving  it  for  the  more  severe  forms.  Supposing  the  latter  to 
amount  to  one  in  four  of  all  the  cases,  this  will  give  us  about  four  thou- 
sand in  eleven  or  twelve  years.  To  those  who  remember  that  the  entire 
number  of  orchitis  cases  in  three  of  our  hospitals,  two  of  them  among  the 
largest  in  London,  was,  for  two  years,  only  eight  hundred  and  forty-four, 
and  that  these  have  to  be  divided  among  ten  assistant  surgeons,  the  num- 
ber operated  on  by  Mr.  Smith  seems  enormous.  This  gentleman  appeals, 
not  only  to  the  success  of  his  own  practice,  but  to  that  of  others  whose 
testimony  he  quotes.  One  of  those,  however,  who  are  exhorted  to  bear 
evidence,  gives  it  against  the  operation,  but  Mr.  Smith  disposes  of  his  ob- 
jections by  saying,  substantially,  that  when  he  knows  more  he  will  know 
better. 

While  according  due  weight  to  the  opinion  of  the  gentlemen  whose 
authority  Mr.  Holmes  quotes  against  the  operation,  and  whose  opinion  I 
should  be  one  of  the  last  persons  to  contest,  I  yet  quite  agree  with  Mr. 
Smith,  that  the  question  is  one  to  be  decided,  not  by  authority  and 
conviction,  but  by  trial  of  the  method  ;  and  I  think  that  he  has  here  the 
advantage  over  his  opponent.  Mr.  Holmes  says  he  cannot  see  how  the 
operation  is  to  do  good,  and  speaks  of  it  as  splitting  the  tunica  ;  the  im- 
mediate answer  to  which  is  that  it  has  done  good,  and  that  the  testicle  is 
simply  pierced  by  means  of  a  bistoury,  from  one-eighth  to  a  sixth  of  an 
inch  broad,  to  a  depth  of  half  or  three-quarters  of  an  inch,  immediately 
after  which  the  blade  is  withdrawn,  so  that  Mr.  Smith  has  modified  his 
earlier  views. 

Mr.  Holmes  goes  so  far  as  to  say,  that  a  large  proportion  of  those  pa- 
tients cited  as  having  been  so  promptly  relieved  by  incision,  are  precisely 
those  whose  sufferings  we  need  in  no  way  particularly  regret.  Whether  stu- 
dents or  costermongers,  they  belong  to  a  class  whose  absence,  whe«  con- 
fined to  their  bed-rooms  by  orchitis,  society  is  the  least  likely  to  lament. 
I  trust  my  readers  will  agree  with  me  in  thinking,  that  it  is  not  desirable 
to  follow  Mr.  Holmes  into  this  part  of  the  argument,  which  may  be  strictly 
correct,  looked  at  from  a  social  point  of  view  ;  but  which  seems  to  me  a 
mistake  in  a  medical  paper,  and  one  the  more  to  be  regretted,  because  his 
deserved  eminence  placed  him  above  the  necessity  for  going  out  of  his 
way. 

It  is  just  possible  that  in  some  few  cases  incision  may  be  a  good,  or 
even  the  best,  remedy.  Thus,  for  instance,  Mr.  Nunn  had  under  him '  a 
case  of  swelled  testicle,  where  suppuration  from  the  same  complaint  in  the 
fellow-gland  had  previously  given  a  great  deal  of  trouble.  In  the  attack 

1  Lancet,  vol.  i.,  p.  158.     1870.. 


TKEATMENT.  193 

for  which  the  patient  was  admitted  under  Mr.  Nunn,  a  third  of  a  grain  of 
morphia  three  times  a  day  had,  at  the  end  of  four  days,  effected  no  im- 
provement, yet  the  operation  proved  quite  successful.  In  undescended 
testicle,  too,  when  affected  by  orchitis,  it  may  turn  out  to  be  useful,  hav- 
ing been  successfully  employed  here  by  Mr.  Johnson  Smith,1  who  punct- 
ured, with  "  a  deep  stab,"  a  testicle  thus  affected,  and  lying  between  the 
external  and  internal  ring  of  the  left  side. 

But  I  believe  that,  as  a  general  rule  of  treatment,  it  will  not  hold  its 
ground.  There  seems  no  doubt  that  in  some  cases  it  did  not  afford  the 
relief  expected  from  it.  The  operation  has  been  given  up  by  some  of  those 
who  saw  it  fairly  tried  and  tried  it  fairly  themselves.  Taking  the  average 
results  on  Mr.  Smith's  own  showing,  they  are  not  more  satisfactory  than 
those  of  Mi\  Gay's  cases,  or  of  my  own  practice. 

M  Aubry,  who  seems  to  have  honestly  studied  the  matter,  did  not  find 
that  puncture  materially  shortened  the  duration  of  the  complaint.2  The 
bulk  of  patients  will  always  shrink  from  operations  of  such  a  nature,  and 
will  rather  risk  mischief  than  face  the  remedy.  There  seems  little  doubt 
that  harm  has  resulted  in  some  cases  from  the  practice,  and  we  know  that 
an  operation,  however  safe  when  skilfully  performed,  will  find  bungling 
imitators  and  will  then  do  mischief. 

Mr.  Spencer  Watson,  in  a  communication  to  be  presently  noticed,  said 
that  he  had  heard  of  one  case,  though  he  had  not  seen  it,  where  atrophy 
followed  incision  into  the  testis,  but  he  hesitates  about  ascribing  this  re- 
sult to  the  operation  ;  I  think,  however,  there  can  be  little  doubt  that  it 
was  the  cause  of  atrophy  in  two  cases  where  M.  Salleron  tried  it,3  as  also 
in  two  mentioned  by  M.  Diday.4  In  the  Giornale  italiano  for  1871 6  there 
is  a  very  short  account,  taken  from  the  Lyon  medical,  of  a  case  in  which 
the  operation  was  followed  by  abscess,  gangrene,  and  hernia  of  the  gland  ; 
and  in  the  following  case  it  was,  whether  skilfully  performed  or  not,  at- 
tended by  consequences  to  all  appearance  of  a  most  lamentable  nature. 

In  the  summer  of  1873  a  gentleman  consulted  me  for  what  he  caUed 
spermatorrhoea,  of  which  he  gave  the  following  account.  More  than  two 
years  previously  he  had  contracted  gonorrhoea  while  at  college.  He  could 
not  tell  me  much  about  the  treatment,  which  seemed  to  have  consisted 
chiefly  of  specifics.  Before  he  had  quite  recovered,  he  was  prevailed  on 
by  some  friends  to  run  a  foot-race  ;  almost  directly  after  he  had  done  so 
the  right  testicle  swelled  badly,  for  which  the  surgeon  who  attended  him 
made  a  free  incision.  This  gave  relief,  a  quantity  of  blood  was  lost  and 
the  swelling  slowly  subsided.  Some  time  afterward,  with  gonorrhoea  still 

'Ibid.,  vol.  i.,  p.  468.    1872. 

2  Annales  des  Maladies  de  la  Peau,  p.  299.     1844. 

3  Archives  Generates  de  Medecine,  tome  i.,  p.  163.    1870. 

4  Annales  de  Dermatologie,  p.  23.     1869. 
6  An.,  vi.,  p.  240. 

13 


194  ON    GONORRHOEA. 

uncured,  lie  was  foolish  enough  to  indulge  in  some  very  hard  rowing, 
whereupon  the  other  testicle  swelled  and  was  similarly  treated  by  the  sur- 
geon. This  time,  however,  the  patient  suffered  a  good  deal  from  pain  in 
the  loins,  followed,  at  a  later  date,  by  obstinate  and  serious  abscess  near 
the  right  tuber  ischii. 

At  the  time  when  the  patient  called  on  me,  he  complained  of  great  and 
increasing  decline  in  sexual  desire,  though  he  was  quite  a  young  man.  I 
endeavored  to  get  some  of  the  semen  for  examination,  but  he  said  that 
he  scarcely  thought  now  of  attempting  connection,  though  previously  his 
passions  had  been  very  strong  ;  and  that  he  never  had  any  emissions,  so 
that  no  supply  could  be  obtained.  I  could  not  discover  with  certainty  in 
what  direction  the  incisions  had  taken  effect ;  the  traces  of  them  were  faint 
and  the  patient  did  not  seem  to  have  noticed  much  about  the  matter  ;  but, 
as  well  as  I  could  make  out,  there  had  been  in  each  case  a  long  cut,  divid- 
ing great  part  of  the  lower  end  of  the  testicle,  and  possibly  part  of  the 
cauda  epididymis. 

Puncture  of  the  Tunica  vaginalis. — This  operation  has  been  recommended 
as  superior  to  the  other  by  Mr.  Spencer  Watson.  In  a  careful  report '  of 
his  practice  we  learn  that,  after  an  experience  of  about  twenty  cases,  he 
finds  it  well  adapted  to  instances  marked  by  effusion  into  the  cavity,  but 
not  to  those  where  the  epididymis  is  alone  or  principally  affected.  Mr. 
Richmond,  however,  in  a  paper  read  before  the  King's  College  Medical 
Society,2  had  previously  borne  testimony  to  the  relief  afforded  by  punctur- 
ing this  membrane  being  quite  as  great  as  when  the  testicle  is  cut  into. 
But  the  results  do  not  tally  with  those  of  Messrs.  Ragazzoni  and  Appiani, 
who  found 3  that,  in  twelve  cases  of  orchitis,  puncture  of  the  tunic  put  an 
end  to  the  affection,  but  that  it  required  twelve  days  to  do  it  in,  and  my 
experience  is  that  mere  rest  would  have  effected  as  much  good.  The 
strongest  condemnation,  however,  passed  upon  it  is  by  Mr.  Watson  himself, 
who  has  abandoned  the  operation,  except  when  there  is  much  effusion  into 
the  tunica  vaginalis,  being  "  inclined  to  think "  that  opium  and  antimony 
give  relief  as  quickly.  I  need  scarcely  say  that  this  looks  very  much  like 
giving  the  method  up  altogether.  At  a  somewhat  later  date  Mr.  Macna- 
mara,  of  Westminster  Hospital,  was  in  the  habit  of  puncturing  the  testicle 
with  a  grooved  needle,  with  excellent  results.4 

As  to  the  treatment  of  orchitis  by  means  of  tartar  emetic  in  friction,  I 
can  only  say,  from  what  I  have  read,  that  it  appears  to  unite  in  itself  all  the 
disadvantages  which  can  possibly  attend  any  method.  One  of  the  medi- 
cal men  who  writes  in  praise  of  it,  warns  his  reader,  that  they  should 
guard  against  the  pustules  coming  out  too  thickly,  as  this  state  may  be  f  ol- 

1  Medical  Times  and  Gazette,  vol.  i.,  p.  520, 1866  ;   and  vol.  i.,  p.  390.     1867. 
8  Ibid.,  vol.  ii.,  p.  479.     1864. 

3  Giornale  italiano,  1870.     Quoted  in  Archiv  fur  Dermatologie,  B.  III.,  S.  57. 

4  Lancet,  vol.  i.,  p.  50.    1877. 


TREATMENT.  195 

lowed  by  "  vicious  "  cicatrices  and  gangrene  of  the  tissues !  Seeing  that 
these  undesirable  results  only  accompany  a  very  moderate  success  in  the 
way  of.cure,  it  is  difficult  to  make  out  what  possible  reason  there  can  be 
for  giving  the  method  a  trial. 

Strapping  the  Testicle  is  now,  I  fancy,  rather  a  matter  of  tradition  than 
of  actual  practice,  and  any  notice  of  it,  therefore,  more  the  offspring  of  a 
desire  to  make  the  author's  work  complete,  than  a  practical  exposition  of 
the  benefits  observed  to  flow  from  the  operation.  I  certainly  think  sur- 
gery will  not  suffer  much  from  its  falling  into  desuetude.  It  is  dirty, 
painful,  and,  generally  speaking,  uncalled  for  ;  and  as  gangrene  has  been 
known, '  though  I  admit  very  rarely,  to  follow  the  employment  of  it,  the  in- 
conveniences of  the  practice  must,  in  my  judgment,  be  held  to  outweigh  the 
.advantages. 

Among  many  other  methods  commended  to  our  notice  are — 1.  Continu- 
ous application  of  ice,  long  ago  employed  by  a  most  careful  surgeon,  Mr. 
Curling,2  with  marked  success,  the  pain  in  the  first  case  recorded  being 
materially  relieved  in  a  day.  Enthusiastically  recommended  by  M.  Diday 
as  infallible  and  relieving  the  pain  within  an  hour,  though  requiring  to 
be  continued  eighteen  to  forty-eight  hours,  and  even  four  or  five  days  ; 
now  apparently  abandoned  by  him  in  favor  of  M.  Langlebert's  method, 
•which  is  opposed  as  any  process  can  well  be.  2.  Freezing  the  testis,  the 
same  process  presumably  under  another  name  ;  seemingly  dead,  and  cer- 
tainly long  disused  at  one  hospital  where  it  was  formerly  much  in  favor. 
3.  The  method  recommended  by  Dr.  Waterman,3  acetate  of  morphia  and 
acetate  of  potass  internally,  tincture  of  iodine  and  ammonia  being  applied 
topically.  4.  That  of  Dr.  Grammer,4  bromide  of  potassium,  five  grains  three 
times  a  day.  5.  The  method  of  Dr.  Julian  Alvarez,5  which  consists  in  the 
application  of  iodoform  ointment,  a  plan  recommended  also  in  the  Union 
Medicale."  6.  That  of  Mr.  Payne,  of  Wallingford,7  painting  the  scrotum 
with  solution  of  iodine,  a  drachm  to  three  ounces  of  spirit,  or  with  strong 
tincture  of  iodine  every  second  day ;  the  cure  in  one  instance  being  so 
rapid  that  by  the  fifth  day  the  patient  was  able  to  resume  his  employment. 
7.  That  of  Dr.  Assadorian,8  constant  application  of  sulphuric  ether,  a 
method  in  the  efficacy  of  which  I  have  great  faith.  8.  Painting  with 
strong  solution  of  nitrate  of  silver,  as  recommended 9  by  Mr.  Furneaux 

1  Medical  Gazette,  vol.  xli.,  p.  976. 

2  Medical  Times  and  Gazette,  vol.  i. ,  pp.  210,  233.     1855. 

3  Practitioner,  vol.  ii.,  p.  334.     1876. 

4  Virginia  Medical  Monthly.     Quoted  in  Louisville  Medical  News,  vol.  ii.,  p.  276. 
1881. 

B  La  Independencia  Medica,  June  1,  1877.  Quoted  in  Lancet,  vol.  ii.,  p.  898. 
1877. 

8  P.  1088.     1881.  7  Lancet,  vol.  L,  p.  131.     1863. 

8  American  Journal  of  Syphilography,  etc. ,  vol.  i. ,  p.  216. 

9  British  Medical  Journal,  vol.  ii.,  p.  202.     1868. 


196  ON    GONORRH(EA. 

Jordan,  which  he  tells  us  will  remove  the  pain,  swelling,  and  tenderness  in. 
twelve  hours.  9.  M.  Bonnafont's  plan  of  applying  collodion.  10.  Com- 
pression in  various  ways  intended  to  be  improvements  upon  strapping.1 
11.  M.  Tachard's  system,  pressure  and  subcutaneous  injections  of  chlor- 
hydrate  of  morphia.2  12.  M.  Langlebert's  method.  13.  Absolute  rest 
alone,  fairly  tried  in  the  Ospedale  maggiore  at  Lodi,  to  my  thinking,  with 
most  indifferent  success,  but  spoken  of  in  the  report  as  the  most  speedy 
method.  Thus,  without  noticing  minor  points  but  including  Mr.  Gay's, 
we  have  nineteen  distinct  systems  of  treatment.  Most  of  these  plans  are 
recommended  as  unfailing  or  nearly  so,  yet  with  the  possible  exceptions  of 
Assadorian's  and  Langlebert's  methods,  I  question  if  a  surgeon,  unfortu- 
nate enough  to  have  contracted  gonorrhceal  orchitis,  who  had  the  full  facts 
of  the  case  put  before  him,  would  prefer  any  one  of  them  to  that  of  Mr. 
Gay,  which  was  not  ushered  into  notice  as  infallible  at  all,  but  as  an  honest 
record  of  facts. 

One  great  question  is  whether  experience  justifies  us  in  the  hope  that 
any  system  of  treatment,  however  thoroughly  its  success  may  have  been 
demonstrated,  stands  a  fair  chance  of  being  generally  adopted ;  and 
whether  medicine  is  not,  in  many  of  its  branches,  so  purely  a  game  of 
hazard,  that  while  a  lecture  on  physiology  at  a  college,  or  the  introduction 
of  a  new  remedy,  will,  as  surely  as  the  summer  sun  calls  certain  forms  of 
being  into  life,  generate  a  host  of  scientific  experiments,  only  too  many  of 
them  aimless  and  barren  ;  of  theories  and  systems  ;  we  cannot  feel  the 
slightest  confidence  that  a  mode  of  treatment,  be  it  ever  so  superior  to  its 
predecessors,  will  even  command  a  hearing. 

Thus,  so  far  back  as  1844,  Mr.  Gay  showed 3  that  orchitis  could  be 
cured  in  half  the  usual  time  by  large  doses  of  hyoscyamus,  a  sharp  purga- 
tive, and  suspension  of  the  testicle.  On  an  average  the  pain  was  relieved 
in  less  than  five  days,  while  the  patients  were  discharged  cured  in  from 
three  to  seventeen  days  or  an  average  of  seven  days  and  a  half.4  Now  with 
the  exception  of  a  note  in  Mr.  Acton's  work,  recording  an  unfavorable  ex- 
perience of  the  method,  I  believe  almost  the  only  notice  taken  of  it  was  in 
former  editions  of  the  treatise  now  before  the  reader.  Mr.  Pitt,  in  a  com- 
munication to  the  Lancet 6  on  this  very  method  of  treating  orchitis,  does 
not  mention  Mr.  Gay's  name  ;  in  the  section  on  this  affection  in  "  Holmes's 
System  of  Surgery,"  it  is  likewise  ignored ;  and  Mr.  James  Rouse,  in  his 
account 6  of  the  treatment  of  orchitis  with  opium,  seems  not  to  have  had 

1  Lancet,  vol.  ii.,  p.  556.  1863.  Archives  medicates  beiges.  Quoted  in  the  Gazette 
des  Hopitaux,  p.  230.  1873.  Medical  Record  U.  S. ,  January  29,  1880.  Australian 
Medical  Journal,  April,  1880. 

5  Rev.  m<^d.  de  Toulouse.  Quoted  in  Gazette  des  Hopitaux,  p.  211.     1874. 

3  Lancet,  vol.  i.,  p.  602.     1844.  6Ibid.,  vol.  ii.,  p.  338.     1848. 

4  Vol.  i.,  p.  429.     1870. 

•  St.  George's  Hospital  Reports,  p.  251.     1869. 


TKEATMENT.  197 

any  idea  that  Mr.  Gay  and  myself  had  recommended  much  the  same  plan 
years  before. 

The  originality  of  the  mode  has  been  contested,  but  the  merit  of  the 
discovery  belongs  to  Mr.  Gay,  and  to  him  alone.  None  of  the  old  authors, 
who  have  been  spoken  of  as  preceding  him  in  this  path,  ever  had  the  most 
remote  idea  of  mastering  the  disorder  by  means  of  sedatives  only,  although 
even  as  far  back  as  the  time  of  Astruc  their  value  as  adjuncts  was  known. 
Swediaur  indeed  seems '  to  have  relied  on  opium  as  a  medicine,  but  his 
great  object  was  to  bring  back  the  "  retropulsed  "  discharge,  retropulsion 
being  in  his  day  something  like  what  blood-poisoning  or  suppressed  gout 
is  in  ours ;  an  ever  busy  demon  which  required  all  the  physician's  skill 
and  watchfulness  to  keep  it  in  subjection  ;  a  skeleton  which  not  only  en- 
joyed a  vested  right  to  a  seat  in  his  consulting-room,  but  rode  with  him  in 
his  carriage,  and  stood  with  him  at  the  patient's  bedside.  To  revert,  how- 
ever, to  the  subject  more  immediately  in  hand,  two  of  the  many  systems 
just  noticed,  the  examination  of  which  was  interrupted  by  this  digression, 
had  better  be  taken  here.  They  are  Bonnafont's  and  Langlebert's. 

M.  Bonnafont  treated  successfully  fifty-six  cases  with  application  of 
collodion,2  the  inflammatory  symptoms  sometimes  disappearing  in  half  an 
hour,  and  the  cure  being  complete  in  two  to  three  days ;  and  all  this  without 
having  in  one  instance  seen  anything  which  contra-indicated  its  employ- 
ment, or  diminished  his  confidence  in  its  powers.  The  pain  from  it  never 
lasted  more  than  two  minutes.  M.  Costes  gave  3  almost  as  glowing  an  ac- 
count. But  M.  Velpeau  found 4  that  it  required  on  an  average  twenty  days 
and  a  half  to  cure  patients  in  this  way.  M.  Kichet  saw 5  frightful  pain  and 
great  excoriation  in  a  case  where  M.  Bonnafont  himself  applied  the  collo- 
dion in  M.  Richet's  presence  ;  and  M.  Venot  found  the  pain  set  up  by 
collodion  intolerable,  while  the  cure  was  so  slow  that  he  abandoned  the 
method  as  useless.6  Lastly,  M.  Kicord  reported7  that  the  pain,  though 
not  of  any  great  duration,  was  generally  severe,  that  he  never  witnessed 
the  rapid  diminution  in  the  volume  of  the  gland  spoken  of  by-M.  Bonna- 
font, and  that  the  results  obtained  were  not  of  a  nature  to  warrant  any 
recommendation  of  the  method. 

M.  Langlebert's  method  consists  in  applying  over  the  swollen  gland  a 
layer  of  carded  cotton,  and  over  this  again  a  piece  of  caoutchouc  cloth. 
The  latter  is  put  on  with  the  glazed  side  toward  the  cotton,  and  over  it  is 
drawn  a  triangular  concave  suspensory  bandage,  with  a  long  strap  at  each 
corner  to  tie  round  the  waist.  M.  Horand  reported  8  most  favorably  to  the 

1  Op.  citat.,  p.  80.  s  Union  Medicale,  tome  viii.,  p.  222.  » Ibid.,  p.  242. 

4  Archives  Generates  de  Mcdecine,  tome  ii.,  p.  613.     1854. 
6  Union  Medicale,  tome  viii.,  p.  249. 

8  Ibid.,  p.  311.  'Ibid.,  p.  449. 

8  Lyon  Medical,  April  14,  1878.  Quoted  in  Medical  Times  and  Gazette,  vol.  i. ,  p. 
552.  1878. 


198  ON    GONORRHOEA. 

Medical  Society  of  Lyons  on  this  method.  His  conclusions  were  based  on 
a  large  number  of  cases,  and  practically  endorsed  by  M.  Diday.  Herr 
Zeissl  also  strongly  approves  of  Langlebert's  system,  which  at  the  date  of 
his  communication  he  had  tried  in  fifty  cases,  and  always  with  "  most  ex- 
cellent results."  In  one  case  which  he  was  called  to,  the  patient,  who  had 
passed  five  nights  without  sleep  (!),  was  suffering  fearful  pain,  every 
motion  and  the  slightest  contact  with  the  testis  causing  him  agony  ;  but 
so  soon  as  the  Langlebert  bandage  was  applied  he  could  get  up  and  walk 
about  the  room  (!).  In  most  of  the  cases  indeed  the  pain  ceased  directly 
the  bandage  was  put  on. 

M.  Fournier's  treatment  of  true  orchitis,  as  he  calls  inflammation  at- 
tacking essentially  the  testicle,  is  of  the  most  heroic  kind — the  freest  pos- 
sible use  of  antiphlogistics  from  the  very  outset,  abundant  and  repeated 
local  bleeding,  baths  for  a  long  time  one  after  another,  strong  belladonna 
inunction,  ice  to  the  testicle,  intestinal  revulsives,  meaning  I  suppose 
strong  purgatives,  and  finally,  at  the  first  suspicion  of  strangulation,  divi- 
sion of  the  tunica  albuginea,  which  some  persons  will  think  might  very  well 
have  preceded  all  this  ;  indeed,  it  is  precisely  for  these  cases  that  Castelnau 
would  reserve  puncture.1 

Proposed  Plan  of  Treatment. — The  plan  of  treatment  now  to  be  de- 
scribed was  worked  out  in  the  same  manner  as  the  other  divisions  of  the 
subject ;  that  is,  one  remedy  at  a  time  was  used  till  its  value  was  ascer- 
tained. 

The  surgeon's  first  object  is  to  arrest  the  pain ;  with  this  the  inflammation 
stops.  The  assertion  has  been  challenged,  I  must  submit,  on  insufficient 
grounds.  Nothing  effects  this  purpose  so  rapidly  and  so  well  as  sedatives, 
and  it  is  surprising  to  me  that  they  should  be  so  little  employed,  when 
their  value  has  been  so  long  and  so  thoroughly  established.  Provided  the 
dose  is  only  large  enough,  the  choice  is  not  of  so  much  moment.  I  prefer 
morphia  myself,  or  Battley's  liquor  opii  in  the  brandy  mixture  of  the  Phar- 
macopoeia, the  latter  being  particularly  useful  when  there  is  a  disposition 
to  nausea. 

The  morphia  may  be  given  in  doses  of  a  fourth  to  half  a  grain  two 
or  three  times  a  day  ;  in  very  severe  cases  three-fourths  of  a  grain  may 
be  given  once  or  twice  in  succession.  To  prescribe  the  twentieth  of  a 
grain  is  simply  to  trifle  with  the  matter.  Similarly,  I  should  never  think  of 
giving  less  than  fifteen  to  twenty  minims  of  Battley's  solution  every  three 
or  four  hours,  and  I  should  in  no  way  hesitate  to  use  much  larger  doses. 
If  there  be  much  prostration,  ammonia  may  be  added  to  either  of  these 
sedatives,  and  the  solution  of  the  acetate  seems  to  suit  very  well  with  the 
morphia  when  there  is  any  feverishness. 

In  the  way  of  external  applications,  I  think  that,  if  the  reader  will  em- 

1  Op.  citat.,  p.  301. 


TREATMENT.  199 

ploy  the  lotion  given !  below,  he  will  be  as  much  pleased  with  its  effects  as 
I  have  been.  One  patient,  who  had  been  taking  sedatives  without  much 
effect  for  two  days,  assured  me  that  he  felt  decided  relief  in  the  first  half- 
hour  after  using  the  lotion,  and  that  he  was,  comparatively  speaking,  well 
the  next  day  ;  but  at  the  end  of  four  days  I  could  still  feel  some  enlarge- 
ment and  considerable  hardness,  both  of  the  testicle  and  epididymis. 
Similar  testimony  has  been  voluntarily  rendered  by  many  patients.  The 
longest  time  I  have  known  to  elapse  before  relief  was  perceived  was  some- 
thing under  three  hours.  But  however  beneficially  the  lotion  may  act,  I 
would  not  advise  entire  abandonment  of  the  sedative  ;  and  whether  this  be 
given  or  not,  the  patient  is  always  the  better  for  a  pretty  free  use  of  warm 
aperients,  such  as  senna  mixture  with  excess  of  tincture  of  cardamoms,  in- 
fusion of  rhubarb  and  coriander  with  sulphate  of  potass,  and  so  on.  A 
light  warm  diet  is  advisable,  starvation  being  useless  as  well  as  hurtful ; 
and  the  patient  should  therefore  be  allowed  to  make  himself  comfortable 
on  a  good  basin  of  mutton  or  chicken  broth,  and  a  little  arrowroot  with  a 
glass  of  old  port  in  it,  and  I  have  even  known  many  patients  to  be  all  the 
better  next  morning  for  a  glass  of  good  whiskey  and  hot  water  over 
night.  I  therefore  always  suggest  a  fair  amount  of  such  stimulants  for  the 
first  night  or  two. 

"When  the  patient  has  been  using  injections,  it  will  be  as  well  to  sus- 
pend the  employment  of  them,  not  for  fear  of  making  the  swelled  testicle 
worse,  but  because  this  disorder  renders  many  persons  languid,  weary,  and 
averse  to  anything  which  occasions  the  least  trouble.  Some  people  also 
still  labor  under  the  opinion  that  the  injections  bring  on  the  swelling  ;  and 
as  the  loss  of  three  or  four  days  is  not  of  much  moment,  while  absolute 
rest  is  a  great  boon  to  such  patients,  it  is  best  to  indulge  them  in  it. 

As  to  the  monstrous  proposal  of  attempting  to  remove  orchitis  by  re- 
storing the  discharge,  I  suppose  it  is  now  entirely  given  up  and  very  justly 
so,  being  not  merely  useless  in  practice,  but  false  even  in  theory  ;  for 
swelling  of  the  testicle  does  not  check  the  discharge — indeed,  the  same 
agency  which  brings  on  the  orchitis  often  increases  the  running,  probably 
in  much  the  same  way  as  anything  does  which  disturbs  the  health,  such  as 
a  cold,  or  an  attack  of  influenza  ;  cold,  dry,  dusty  winds  ;  the  over-free  use 
of  stimulants,  etc. 

I  can  safely  say  that  I  never  saw  an  unequivocal  instance  of  gonorrhoea 
arrested  by  swelled  testicle  coming  on.  The  patient  often  thinks  so,  but 
one  glance  is  generally  enough  to  show  that  it  is  present ;  and  when  the 
two  events  really  occur  at  the  same  time,  they  are  simply  a  coincidence, 
not  cause  and  result.  In  the  worst  case  of  orchitis  I  ever  had  under  my 
care,  first  the  right  testicle  swelled  and  then  the  left.  I  was  not  called  in 

1  3 .  Liq.  ammon.  acetatis,  3!.;  Spir.  setheris,  3  iss. ;  Mist,  campk. ,  §  iiiss.  M.  ft. 
lotio.  Signa.  To  be  applied  by  means  of  a  single  fold  of  linen,  which  is  continuously 
wetted  with  the  fluid. 


200  ON    GONOKRHCEA. 

till  the  latter  gland  was  affected,  and  then  I  found  not  only  considerable 
tenderness,  swelling,  and  hardness  of  the  right  testis  still  remaining,  but 
very  evident  symptoms  of  what  might  fairly  be  called  most  severe  inflam- 
mation in  the  other,  accompanied  by  visible  swelling  over  the  lower  part 
of  the  spermatic  cord.  The  patient,  a  strong  young  fellow,  complained  of 
such  excruciating  pain,  especially  over  the  cord,  that  I  could  hardly  help 
fancying  he  exaggerated  ;  but  his  mother  and  sisters  assured  me,  that  he 
had  been  delirious  from  the  pain,-  and  that  such  a  condition  could  not,  in 
his  case,  be  due,  either  to  stimulants  or  medicines,  for  he  had  done 
nothing  but  apply  hot  linseed  poultices,  and  was  extremely  temperate. 
Here  I  satisfied  myself  by  examination  that  the  discharge  from  the  urethra 
was  still  profuse,  and  the  patient  said  it  had  been  so  all  through.  The 
reader  will  find,  further  on,  another  case  of  double  orchitis  accompanied 
by  discharge. 

If  any  of  my  readers  appeal  to  authority,  and  say  that  in  a  simple 
matter  of  fact  like  this  it  is  impossible  so  many  excellent  observers — num- 
bering among  them  Brodie,  Swediaur,  Cooper,  Larrey,  Wallace,  and  many 
others 1 — could  have  deceived  themselves,  I  meet  the  objection,  first,  by 
asking  them  to  use  their  own  eyes  and  ears  ;  and  secondly,  by  referring 
them  to  Curling,  Fournier,  and  Bicord,  who,  basing  their  conclusions  on 
an  immense  number  of  cases,  have  decided  against  the  old  doctrine.  M. 
Ricord  says 2  that  if  arrest  of  the  gonorrhceal  discharge  take  place,  it  is  not 
above  once  in  two  hundred  times ;  M.  Fournier  observes  that  quite  as 
often  as  not  the  discharge  is  in  no  way  affected  ;  and  Mr.  Curling,3  speak- 
ing of  its  suppression,  or  rather,  strictly  speaking,  metastasis  to  the  testi- 
cle, says,  it  is  very  questionable  whether  anything  of  the  kind  happens  in 
genuine  orchitis.  M.  Robert,  in  thirty-eight  cases,  found  the  discharge 
pretty  abundant  in  twenty-six,  while  it  could  be  detected  in  every  one  of 
the  remaining  twelve.  It  may,  however,  be,  and  often  is,  diminished,  but 
that  is  a  different  question.  It  is  almost  superfluous  to  say  that  the  patient 
requires  a  well-fitted  suspensory  bandage. 

Blistering  the  Scrotum. — When  the  swelling  and  pain  continue  very  ob- 
stinate, the  surgeon  may,  at  the  end  of  a  few  days,  blister  the  scrotum. 
Very  alarming  pictures  of  the  results  to  be  expected  have  been  drawn  ; 
but  as  I  have  never  met  with  them,  I  object  to  giving  up  the  teachings  of 
experience  for  the  sake  of  conforming  to  theoretical  objections.  I  have  seen 
a  blister  check  or  limit  an  abscess  of  the  scrotum  when  it  was  almost  point- 
ing, and  hold  such  testimony  of  the  action  of  cantharides  to  be  better  evi- 
dence than  the  fears  of  inexperience. 

Several  years  ago,  one  of  the  physicians  at  the  Infirmary  of  Bishopwear- 
mouth  ordered  a  blister  to  be  applied  to  the  epigastric  region  of  a  patient 


1  Medical  Times  and  Gazette,  vol.  ii.,  p.  271.     1871. 

5  Trait'J  Pratique,  p.  754.  3  Op.  citat.,  p.  243. 


TREATMENT. 


201 


suffering  under  great  pain  in  that  part  of  his  animal  economy.  The  pa- 
tient, being  told  to  put  the  blister  upon  the  epigastric  region,  and  thinking 
this  was  only  a  jocular  term  for  the  organs  of  generation,  actually  cut  a 
hole  in  the  blister,  pulled  the  penis  through,  and  carefully  fastened  the 
vesicant  on  the  scrotum.  Two  days  afterward  his  landlady  came  to  the 
infirmary  to  say  that  the  man  was  dreadfully  ill ;  and,  sure  enough,  when 
the  surgeon  went  he  was  in  woful  plight,  having  kept  the  blister  on  ah1 
this  time  ;  but  the  serious  symptoms,  which  some  authors  profess  to  ex- 
pect from  three  or  four  hours'  blistering,  had  not  ensued  at  all ! 

Kegarding  the  treatment  of  the  blistered  surface,  I  must  refer  my 
reader  to  the  section  on  blistering  in  the  fourth  chapter,  where  he  will 
find  full  directions. 

I  wish  it  to  be  understood  that  I  do  not  recommend  the  above  method 
either  as  infallible,  or  as  possessed  of  any  marvellous  efficacy.  So  far, 
and  especially  as  regards  the  use  of  ammonia  and  ether,  it  has  not  failed 
in  my  hands,  and  I  consider  experience  warrants  me  in  saying,  that  it  has 
answered  better  than  any  method  which  I  have  seen  tried,  but  I  do  not  go 
beyond  this. 

Subsequent  Treatment. — So  soon  as  ever  the  symptoms  of  active  in- 
flammation have  subsided,  iodide  of  potassium  may  be  ordered,  alone  or  in 
combination  with  liquor  potassse,  with  the  view  of  removing  the  hardness 
and  swelling.  A  small  quantity  of  mercury  and  chalk  every  second  night 
will  often  assist  the  action  of  these  remedies.1  I  suppose  it  would  now  be 
fighting  with  a  shadow  to  attack  the  doctrine  that  the  use  of  iodide  of 
potassium  may  lead  to  wasting  of  the  testis  ;  but  it  may  be  as  weh1  to  ob- 
serve that  the  credulity  with  which  this  doctrine  was  at  once  received, 
and  the  ex  cathedrd  style  in  which  it  was  taught  for  years  vnthout  one  per- 
son being  found  to  undertake  the  task  of  really  looking  into  the  subject,  ought, 
if  experience  could  ever  do  so,  to  make  men  more  cautious  about  adopt- 
ing tenets  on  such  evidence,  or  rather  on  no  evidence  at  all. 

I  need  scarcely  say  that  should  effusion  of  serum  take  place  into  the 
vaginal  sac,  an  accident  which  has  never  once  occurred  in  a  case  where  I 
had  charge  of  the  patient  from  the  beginning,  puncture  must  be  resorted 
to.  When  the  effusion  is  abundant  a  very  fine  trocar  may  be  employed ;  I 
use  one  only  about  twice  the  thickness  of  an  insect  needle.  For  slighter 
degrees  I  have  found  acupuncture  sufficient. 

Most  of  the  cases  treated  in  this  way  have  been  thoroughly  cured  ;  in- 
deed, so  far  as  has  been  ascertained,  success  always  followed  a  fair  trial, 
and  none  of  the  patients  suffered  from  a  relapse — most  encouraging  re- 
sults, when  we  consider  how  often  authors  have  told  us  of  the  tendency 

1  IJ.  Potassii  iodidi,  3]'.;  potassse  liquoris.  3iij.;  syrupi  flor.  aurant.,  3  iv. ;  tinct. 
cinnam.  co.  ad  §  iv.  M.  Capiat  coch. ,  min.  ij.  ter  quotidie  ex  aquae  cyatho  vin.  1J. 
Hydranryri  cum  creta,  gr.  xij.;  pulv.  cinnam.  compos.,  gr.  viij.  M.  et  divide  in  pulv. 
vj.  Sumat  j.  omni  nocte. 


202  ON    GONORRHCEA. 

this  disorder  has  to  return  under  any  form  of  treatment.1  I  do  not,  how- 
ever, say  it  is  infallible  ;  I  only  say  it  has  succeeded  in  my  hands  much 
better  than  any  other. 

M.  Castelnau  gives a  a  very  different  account  of  how  matters  may  go. 
According  to  him  orchitis  may  become  chronic.  After  doing  well  for  a 
time,  the  improvement  suddenly  stops,  and  the  testicle  even  augments  in 
volume  ;  or  the  acute  orchitis  may  subside  and  the  patient  suddenly  find 
that  it  has  returned.  The  same  parts  are  affected  as  in  the  acute  form, 
except  that  the  spermatic  cord  is  much  more  frequently  implicated.  The 
epididymis  is  more  voluminous,  hard,  sometimes  smooth,  more  often  un- 
equal ;  presenting  knobs  in  which  the  induration  is  more  marked  than  else- 
where. The  testicle  is  by  no  means  so  much  enlarged,  and  appears  let  into 
the  antero-inferior  part  of  the  epididymis  which  is  depressed  to  receive 
it.  I  never  yet  saw  the  progress  toward  cure  interrupted  by  any  such 
symptoms  and  must  conclude  that  M.  Castelnau  has  confounded  syphilitic 
sarcocele  with  gonorrhoeal  orchitis. 

Deferentitis. — A  case  of  this  is  mentioned3  by  M.  Gosselin.  It  oc- 
curred on  the  left  side,  the  swelling  being  below  the  external  inguinal 
ring  and  almost  on  a  level  with  the  head  of  the  epididymis.  It  was  very 
hard,  slightly  painful  to  the  touch,  and  about  the  size  of  a  big  hazel-nut. 
From  it  issued,  below,  a  hard  cord  about  the  size  of  a  quill,  which 
stretched  from  it  to  the  tail  of  the  epididymis.  From  above,  another 
cord,  larger  than  the  former,  could  be  traced  to  the  external  inguinal 
ring,  and  from  this  to  the  upper  opening  of  the  inguinal  canal.  The  tes- 
ticle and  epididymis  were  quite  distinct.  The  affection  rapidly  subsided 
under  the  influence  of  rest,  purgatives,  and  mercurial  inunction,  and  at 
the  end  of  sixteen  days  only  the  slightest  trace  of  it  was  found. 

Inflammation  of  the  spermatic  cord  without  affection  of  the  correspond- 
ing testicle,  as  described  by  Bergh,4  Wahrmann  and  Kohn,5  I  have  not 
met  with.  In  the  case  of  double  orchitis  previously  mentioned  this  symp- 
tom was  evidently  present  in  one  cord,  and,  from  the  patient's  account, 
had  occurred  in  the  other.  He  complained,  however,  so  much  of  the  ten- 
derness in  the  affected  parts  that  I  could  not  make  a  proper  examination, 
and  he  was  admitted  as  an  in-patient  into  another  hospital  three  or  four 
days  after  my  first  seeing  him.  My  experience,  therefore,  of  the  affection 
is  valueless.  I  need  scarcely  remark  that  great  pain  near  the  external  ring 
is  in  no  way  uncommon.  The  symptoms  in  the  case  described  by  Kohn 
were  very  severe.  A  case  which  seems  identical  with  those  just  given  is 

'Johnson:    On  the  Genito-Urinary  Organs,  p.  194.  2Op.  citat.,  p.  324. 

3  Gazette  des  Hopitaux,  p.  261.     1868. 

4  Hospitals-Tidende,  No.  49,  December,  1848.     Quoted  in  the  Archiv  fur  Dermato- 
logie,  B.  I.,  S.  605. 

6  Wiener  medizinische  Presse,  p.  17.  1870.  Quoted  in  the  Archiv  fur  Dermatologie^ 
B.  IH.,S.  58. 


TREATMENT.  20.'* 

• 

mentioned  by  Hunter. '  M.  Fournier,  speaking  of  this  and  def erentitis, 
says 3  be  has  only  seen  two  instances,  but  of  which  he  does  not  precisely 
specify.  At  a  later  date  he  mentions 3  two  instances  in  which  the  gonor- 
rhoea! inflammation  was  seated  in  the  vas  deferens  without  the  epididymis 
being  affected. 

6 — 7.  PHIMOSIS  AND  PAKAPHmosis.4 — The  treatment  of  these  complications 
may  be  summed  up  in  a  very  few  words.  Phimosis  seldom  calls  for  more 
than  suspension  of  the  penis,  which  may  be  easily  effected  by  any  person 
possessed  of  the  most  ordinary  mechanical  skill.  In  the  more  severe 
cases,  such  as  are  occasionally  seen  when  ineffective  attempts  have  been 
made  to  check  the  disorder  with  specific  medicines,  and  which  never  ensue 
when  injections  are  properly  employed,  evaporating  lotions  containing 
ether  and  acetate  of  ammonia  may  be  used  ;  I  have  never  seen  a  recent 
case  which  required  more  than  these.  So  soon  as  ever  the  prepuce  can 
be  drawn  back  far  enough  to  admit  the  syringe,  the  treatment  may  be 
continued  just  the  same  as  if  there  were  no  phimosis.  It  is  quite  a  mis- 
take to  imagine  that  this  complication  proves  the  presence  of  an  amount 
of  inflammation  which  would  render  the  use  of  injections  dangerous.  In 
some  long-standing  cases  it  is  necessary  to  act  with  decision,  as  I  have 
seen  nearly  the  whole  prepuce  ulcerated  or  adhering  to  the  glans.  The 
affair  is,  however,  so  simple  as  scarcely  to  require  any  rules  at  ah1,  and  I 
should  not  have  done  more  than  merely  allude  to  it,  had  not  such  an  un- 
necessary amount  of  words  been  expended  on  what  every  apprentice  ought 
to  be  able  to  manage. 

"When  division  of  the  foreskin  is  necessary  the  director  should  be  passed 
under  it  in  the  mesial  line,  and  when  the  point  will  reach  no  farther,  the 
skin  is  drawn  well  toward  the  root  of  the  penis.  The  skin  and  mucous 
membrane  are  then  cut  clean  through  to  the  point.  One  necessary  pre- 
caution is  not  to  introduce  the  director  into  the  urethra  and  slit  up  the 
glans.  The  reader  may  think  this  caution  superfluous,  but  I  have  known 
a  very  good  surgeon  make  the  mistake.  Mr.  Johnson  has  also  seen  it 
happen. &  Any  warty  growths  found  inside  may  be  touched  with  a  strong 
astringent,  such  as  glacial  acetic  acid,  etc. 

Dr.  Durkee  tells  us  that  phimosis  will  sometimes  yield  to  gradual  dis- 
tention  with  a  sponge-tent,  and  a  very  ingenious  friend  of  mine  invented 
an  expanding  ring  which  he  assured  me  never  failed  to  remove  the  con- 
striction. Mr.  Travers  also  speaks  of  a  dilating  instrument  invented  by 

Trew.     But  I  apprehend  that  such  measures  as  these  are,  like  circum- 

< 

1  Op.  citat.,  p.  54  sNouveau  Dintionnaire,  tome  v.,  p.  214. 

3  Archives  Generates  de  Medecine,  tome  ii.,  p.  390.     1877. 

4  The  modern  spelling  of  these  words  seems  to  me  a  mistake,  the  Greek  v  having 
much   more  analogy  with  y  than  with  i.     However,  as  scholars  like  Hooper  and  Good, 
admit  the  innovation,  anything  beyond  protest  would  be  superfluous. 

6  Op.  citat.,  p.  136. 


204  ON    GOXORREKEA. 

cision,  stilted  more  for  cases  in  which  there  is  no  gonorrhoea  to  complicate 
them.  There  is  one  complication  which  I  shall  advert  to  presently,  in 
which  I  think  it  highly  advisable  to  divide  the  prepuce  at  the  least. 

As  to  paraphimosis  little  need  be  said.  The  surgeon  should  carefully 
cleanse  the  penis,  and  then  attempt  the  reduction  of  the  strangulated  part, 
in  which  with  a  little  perseverance  he  will  generally  succeed.  Some 
authors,  Fricke  among  the  number,  profess  to  have  never  failed.  I  have 
not  been  so  fortunate,  and  I  have  seen  much  better  surgeons  than  myself 
make  the  attempt  ineffectually.  Rollet  candidly  admits  *  failure.  This, 
however,  is  not  of  much  importance,  as  in  gonorrhoea,  if  properly  treated, 
the  strangulation,  when  not  neglected,  is  never  severe  and  rarely  attains 
such  severity  as  to  require  cutting  of  the  constricting  band.  If  it  should, 
the  evil  is  easily  met.  In  the  good  old  times  of  Musitanus,  once  a  great 
authority  in  those  matters,  the  doctors  seem  to  have  made  sharp  work  with 
the  swelling  from  paraphimosis.  The  plan  was  to  "  humble  the  crystalline 
[the  swelling]  with  sublimate,"  and  then  touch  the  affected  part  with  tinct- 
ure of  tobacco,  which  was  "  to  be  done  when  the  patient  is  lying,  lest  the 
Violence  of  the  Pain,  because  of  the  violent  operation  of  the  Tincture,  should 
make  him  drop  down  in  convulsions  ! " :  Even  much  later  it  was  quite  a 
common  thing  to  take  off  part  of  the  organ  in  these  cases. 

Dr.  Mason  Good  tells  us  that  in  this  "  variety,  amputation  of  a  larger  or 
smaller  portion  of  the  penis  may  be  necessary."  (!)3  I  must  say  this  is  a 
consolatory  view  to  take  of  the  matter,  and  the  reader,  if  he  ever  suffer 
from  paraphimosis,  may  thank  Heaven  that  Dr.  Good  is  not  alive  and  likely 
to  attend  him.  Why,  in  the  very  worst  cases  it  would  be  far  better  not  to 
meddle  with  the  affair,  as,  when  gangrene  ensues  the  utmost  that  can 
happen  is  that  the  loose  part  of  the  prepuce  is  thrown  off.  Even  this,  I 
apprehend,  must  be  extremely  rare.  Dr.  Durkee 4  speaks  of  it  as  a  fact 
"  which  the  medical  attendant  sometimes  witnesses."  I  have  not  myself 
seen  it  from  gonorrhoea. 

8.  BALANITIS  is  one  of  the  most  easy  complications  to  deal  with,  although 
some  attempts  have  been  made  to  bring  it  within  the  category  of  complaints 
requiring  extraordinary  means.  M.  Kicord  advises  cauterization,  and  if 
the  patient  be  quite  indifferent  as  to  the  amount  of  pain  he  may  suffer,  or 
perhaps  rather  prefer  it,  caustic  will  answer  as  well  as  mild  lotions  of 
sulphate  of  zinc  in  camphor  mixture,  four  grains  to  an  ounce  ;  or  sulphate 
of  copper  in  rose-water  of  the  same  strength,  syringed  under  the  foreskin 
two  or  three  tunes  daily,  when  this  is  tight,  and  applied,  when  the  foreskin 


1  Recherches  Cliniques  et  Experimentales,  p.  548.     1869. 
"Cockburn:  Op.  citat.,  p.  246. 

3  When  gonorrhoea  was  considered  to  be  syphilis,  the  removal  of  the  organ  seems  to 
have   been  a  dernier  re*s&rt.     "  Amputation  of  the  penis,"  says  Cockburn  (p.   224), 
"  has  often  been  the  last  remedy  for  the  sharp  matter  of  the  gonorrhrea." 

4  Op.  citat. ,  p.  78. 


TREATMENT.  205 

can  be  drawn  back,  by  means  of  a  strip  of  thin  linen  soaked  in  the  solution 
used  and  laid  between  the  prepuce  and  glans  ;  but  according  to  my  expe- 
rience no  better. 

Mr.  Acton  '  speaks  of  gangrene  as  though  it  was  not  an  unfrequent  re- 
sult of  balanitis,  and  tells  us  that,  though  it  generally  attacks  the  prepuce, 
it  may  destroy  the  whole  penis.  M.  Robert  seems  quite  familiar  with 
gangrene  of  the  loose  fold  of  the  prepuce  from  this  cause.  Although  for 
years  I  saw,  quite  twice  weekly,  specimens  of  the  worst  class  of  cases  in  the 
Metropolitan  and  Royal  Free  Hospitals,  I  never  observed  an  instance  of  this. 

The  occurrence  seems  to  have  been  common  enough  when  men  did  not 
discriminate  carefully  between  syphilis  and  gonorrhoea/  but  I  should  think 
it  must  be  almost  unknown  now  in  good  practice.  It  will,  I  trust,  be 
unnecessary  to  say  anything  about  the  treatment  of  posthitis,  the  elevation 
of  which  into  a  separate  subdivision  seems  to  me  rather  a  refinement. 

9.  INFLAMMATORY  SWELLING  OF  THE  PENIS. — I  should  scarcely  have  been 
inclined  to  look  upon  osdematous  swelling  of  the  organ,  even  accompanied 
by  balanitis,  as  a  very  serious  affair,  and  have  been  disposed  to  think  that 
rest  in  bed  for  a  day  or  two,  a  sedative,  and  the  free  use  of  tincture  of  steel, 
with  spirit  lotions,  were  all  that  is  requisite.  Some  of  the  French  surgeons, 
however,  evidently  view  it  as  a  symptom  of  sufficient  importance  to  require 
the  most  heroic  treatment. 

The  parts,  says  M.  Melchior  Robert,  are  to  be  enveloped  in  linen  steeped 
in  marsh-mallow  water,  elder-flower  water,  or  any  other  emollient  fluid. 
If  there  be  no  reaction,  it  is  not  necessary  to  do  more  than  apply  leeches  to 
the  groin  or  perineum, ;  but  if  the  system  be  seriously  affected,  blood  is 
to  be  taken  once  or  twice  from  the  arm.  Constipation  is  to  be  removed 
by  purgative  salines  such  as  seidlitz  powders,  sulphate  of  soda,  and  citrate 
of  magnesia.  Along  with  these  we  may  use  warm  baths,  but  not  fomen- 
tations or  cataplasms.  The  seat  of  the  discharge  is  to  be  frequently 
cleansed  with  emollient  lotions  or  injections,  almost  cold,  to  prevent  pain- 
ful erections.  Pills  and  enemata  of  camphor  may  be  given,  and  conversa- 
tion or  reading  calculated  to  inspire  lascivious  ideas  (!)  is  to  be  strictly 
excluded.  In  order  to  avert  gangrene,  solution  of  opium  may  be  injected 
into  the  cavity  between  the  glans  and  the  prepuce.  All  this,  however,  and 
several  other  remedies  to  boot,  such  as  decoction  of  mulberry-leaves,  do 
not,  it  appears,  always  prevent  part  of  the  penis  from  being  destroyed  by 
mortification. 

I  certainly  should  not  think  injecting  opium  was  very  likely  to  stay 
gangrene,  but  how  this  accident  occurs  af  all  is  more  than  I  can  make  out. 
I  have  seen  and  treated  some  rather  bad  cases  of  oedematous  swelling  of 
the  penis,  but  I  cannot  call  to  mind  such  results  as  sphacelus,  and  should 

'Op.  citat.,  p.  71. 

8  Swediaur :  Op.  citat. ,  p.  130.  Surgical  Essays.  By  Sir  Astley  Cooper  and  Mr. 
Benjamin  Tr avers.  Part  i.,  p.  151.  1818. 


206  ON    GONORRHOEA. 

not  feel  very  well  satisfied  if  they  occurred  when  under  my  care.  Such  a 
complication  as  erysipelas  of  the  penis  and  scrotum,  which  must,  I  fancy, 
be  very  rare,  should  be  met  with  large  doses  of  tincture  of  the  sesqui- 
chloride  of  iron  every  three  hours,  and  the  application  of  any  innocuous 
fatty  substance,  such  as  benzoated  zinc  ointment  applied,  melted,  all  over 
the  affected  part.  When  it  attacks  the  dartos,  free  incision  is  recom- 
mended by  some  authors.1  t 

10.  INFLAMMATION  OF  THE  SPONGY  AND  CAVERNOUS  BODIES. — The  reader  will 
find  a  very  good,  and  rather  amusing,  account  of  these  affections  in  Mr. 
Johnson's  work  on  the  genito-urinary  organs.  They  are  both  intractable 
enough,  but  it  can  hardly  be  said  that  they  interfere  with  the  cure  of 
gonorrhoea,  as  they  rarely  if  ever  show  themselves  except  when  the  patient 
has  thoroughly  neglected  his  complaint,  and  indeed  are  rather  results  than 
complications.  They  are  extremely  uncommon,  and  inflammation  of  the 
cavernous  bodies  is  perhaps  the  most  rare  of  all  the  sequelae  of  gonorrhoea. 
One  gentleman,  who  consulted  Mr.  Johnson  for  it,  suffered  lancinating 
pains  on  erection,  and  his  penis  twisted  like  "  a  pig's  curly  tail."  It  re- 
sisted the  most  energetic  treatment,  and  when  last  heard  of  the  patient  was 
little  if  any  better.  In  the  fatal  case  of  chordee,  mentioned  previously, 
which  occurred  hi  the  practice  of  M  Villeneuve,  these  bodies  were  im- 
plicated. M.  Robert,  whose  account  of  induration  of  the  corpora  caver- 
nosa *  is  very  clear  and  concise,  gives  an  unfavorable  prognosis.  I  have 
only  seen  two  cases,  one  of  the  posterior  portion  of  the  spongy  body,  one 
of  the  left  cavernous  body,  both  in  only  a  slightly  pronounced  form. 
Neither  of  the  patients  could  be  induced  to  undergo  any  treatment  for  his 
complaint. 

1  The  merits  of  first  noticing  this  affection,  and  suggesting  incision  for  it,  has  been 
ascribed  to  Mr.  Liston,  but  I  believe  it  is  due  to  Mr.  Johnson. 
sOp.  citat.,  p.  167. 


CHAPTER  YI. 

TREATMENT  (CONTINUED). 

COMPLICATIONS  WHICH  INTERFERE  WITH  THE  CURE  or  GONORRHOEA. — We  now 
arrive  at  the  consideration  of  those  symptoms  which  are  more  calculated  to 
fetter  the  surgeon's  hands.  From  their  importance  I  have  been  led  to 
illustrate  them  by  a  few  carefully  selected  cases,  for  which  I  solicit  the 
reader's  earnest  attention. 

Under  this  head  I  propose  to  place  all  those  affections  which  directly 
or  indirectly  interfere  with  the  exhibition  of  proper  remedies.  They  con- 
sist of — 

1.  FAINTING  FROM  THE  USE  OF  INJECTIONS. — In  speaking  of  a  strong  tendency 
to  faint  from  the  use  of  injections,  I  allude,  not  to  the  mere  sense  of  faint- 
ness  felt  on  passing  the  tube  of  the  syringe  down  the  urethra  for  the  first 
time,  as  that  is  quite  a  common  affair,  but  to  that  form  where  the  disposi- 
tion is  so  strong  and  recurs  so  constantly  as  to  constitute  an  idiosyncrasy. 
I  have  seen  it  in  very  strong  men. 

An  acrobat  who  had  contracted  a  discharge  came  under  my  care.  He 
was  a  healthy,  temperate  man,  a  solid  mass  of  bone  and  muscle.  His 
energetic  method  of  gaining  his  livelihood  was  practised  "sub  Jove,"  and 
had  developed  his  powerful  frame  to  the  highest  pitch  of  health  and  strength 
it  was  capable  of.  Yet  this  man  fainted  so  suddenly  on  my  attempting  to 
insert  a  short  syringe  into  the  urethra,  that  he  fell  like  a  stone.  The  in- 
sensibility was  very  prolonged,  and  he  felt  so  ill  after  it  that  he  refused 
to  have  any  more  injections. 

A  gentleman  consulted  me  for  gonorrhoea.  He  was  a  remarkably  strong 
man,  exceedingly  well  made,  and  wore  the  appearance  of  being  in  very  high 
health  ;  he  was  fifty  years  of  age,  and  told  me  that  he  had  never  taken  a 
dose  of  physic  since  he  was  a  child,  and  never  remembered  having  experi- 
enced the  feeling  of  being  out  of  health.  He  had  never  had  a  cold,  he 
said,  or  a  headache.  The  introduction,  however,  of  only  the  tip  of  the 
syringe  produced  such  an  effect  upon  him  that  he  begged  of  me  to  -with- 
draw it,  as  otherwise  he  should  faint  on  the  spot,  and  immediately  after 
broke  out  into  such  a  cold  perspiration  that  I  saw  it  would  be  useless  to 
continue  the  attempt. 

A  cavalry  officer,  a  strongly  built,  hard-featured,  resolute-looking  man, 


208  ON    GONORRHOEA. 

consulted  me  for  slight  occasional  discharge  from  the  urethra,  and  great 
irritability  of  the  passage  for  about  half  an  inch  down.  I  wished  to  give 
him  two  or  three  injections,  and,  according  to  my  regular  custom,  asked 
him  before  using  the  first  one  if  he  thought  it  was  at  all  likely  that  he 
would  suffer  in  this  way.  He  seemed  quite  satisfied  that  he  should  not 
do  anything  of  the  kind,  but  the.  event  showed  he  was  widely  mistaken, 
and  that  if  I  had  been  imprudent  enough  to  repose  faith  in  his  assurances 
he  might  have  been  hurt ;  for  I  had  scarcely  got  the  tip  of  the  syringe 
into  the  urethra  before  he  suddenly  exclaimed  that  he  was  going  to  faint, 
and  it  was  as  much  as  I  could  do  to  save  him  from  falling  heavily.  He 
remained  perfectly  blanched,  sick  and  prostrate  for  a  considerable  time. 

I  was  beginning  to  inject  a  gentleman,  a  strong,  finely  grown,  healthy- 
looking  young  fellow.  Almost  in  an  instant,  as  the  instrument  had  en- 
tered the  urethra,  he  turned  pale  and  fell  almost  like  a  corpse ;  but,  as 
I  have  learned  to  expect  this  kind  of  thing,  I  was  enabled  to  break  his  fall. 
The  pulse  at  the  radial  artery  stopped  completely.  On  coming  to  himself 
he  discharged  the  contents  of  his  stomach  almost  at  a  single  gush,  and  it 
was  a  long  time  before  he  so  far  recovered  as  to  be  able  to  leave  the  room. 

In  my  opinion  the  surgeon,  unless  he  happen  to  know  the  constitution 
of  his  patient,  should  always  be  prepared  for  such  a  contingency  ;  and 
when  he  has  satisfied  himself  that  there  is  a  disposition  to  syncope,  or  even 
has  good  reason  to  suspect  it,  then  he  had  better  give  the  injection  with 
the  patient  in  a  sitting  or  lying  posture.  This  will  overcome  the  most  ob- 
stinate disposition  to  fainting,  as  the  following  instance,  among  many 
others,  may  show. 

A  very  tall,  delicate  young  gentleman  applied  to  me  with  gonorrhoea. 
About  eighteen  months  previously  he  had  suffered  from  an  attack,  which, 
with  all  possible  care,  was  not  subdued  with  copaiba  and  salines  in  less 
than  nine  months ;  ever  since  then  the  urethra  had  remained  extremely 
tender,  and  whenever  he  had  a  cold,  a  drop  of  pus  was  seen  at  the  meatus 
on  rising.  On  inserting  the  syringe  he  immediately  fainted,  and  as  soon 
as  ammonia  was  applied  to  his  nostrils  the  contents  of  his  stomach  were 
thrown  off ;  but  the  impression  made  upon  the  disease  was  so  evident  that 
the  patient  willingly  continued  the  injections,  which  were  given  sitting. 
At  the  end  of  eleven  days  the  discharge  was  so  far  diminished  that  they 
were  only  given  every  second  day,  and  then  every  third  till  the  twenty- 
fifth,  which  was  the  last,  no  discharge  having  been  seen  for  eight  days. 
The  faintness  was  present  to  the  last. 

Some  months  later,  during  an  excursion  in  Austria,  he  again  contracted 
the  disorder ;  he  was  treated  with  specifics  and  derived  almost  as  little 
benefit  from  them  as  before.  Soon  after  his  return  to  England  he  con- 
tracted a  fresh  infection,  and  six  months  subsequently  he  had  another  at- 
tack. On  both  these  occasions  the  complaint  was  removed  within  a  week 
by  means  of  injections,  but  the  tendency  to  faint  was  still  as  strong  as 


TREATMENT,  209 

ever  when  beginning  with  them.  After  the  last  gonorrhoea  I  recom- 
mended the  use  of  a  gum-elastic  bougie  twice  a  week.  To  the  very  last 
day  of  using  it  he  always  averted  his  sight  from  the  instrument,  feeling 
sure  that  he  would  swoon  if  he  looked  at  it.  This  treatment,  I  may  ob- 
serve, answered  the  end  in  view ;  the  patient,  though  he  was  soon  as  im- 
prudent as  ever,  contracted  no  more  gonorrhoeas. 

2.  GREAT  NATURAL  OR  INDUCED  WEAKNESS. — By  this  is  meant,  not  so  much 
great  physical  exhaustion,  as  a  weak,  irritable  state  of  the  system.  The 
patient  is  gloomy  and  weary  ;  sometimes  prostrated  with  sick  headaches, 
at  other  times  scarcely  able  to  rise  from  mere  lassitude.  A  cold  confines 
him  for  a  week,  his  bowels  are  costive,  his  tongue  coated,  his  enjoyment 
of  all  comforts  is  lost,  and  he  broods  and  frets  over  even  a  slight  persist- 
ence of  his  malady. 

These  cases  are  often  exceedingly  difficult  to  manage.  Specifics  and 
potass  are  sometimes  badly  borne,  and  the  operation  of  such  remedies  as 
seem  suited  to  the  health  is  unsatisfactory  as  regards  the  gonorrhoea. 
Tonics  can  only  be  taken  for  a  little  time,  as  the  discharge  is  apt  to  be- 
come exasperated  when  their  action  is  kept  up  for  long.  Many  patients 
of  this  class  can  hardly  be  induced  to  take  aperients,  though  positively  re- 
quired ;  and  they  are  so  sensitive  to  pain,  that  they  shrink  from  injections 
which  are  indispensable.  It  is  impossible  to  lay  down  any  rules  for  a  sys- 
tem of  treatment  generally  adapted  to  these  cases,  as  so  very  much  will 
depend  on  the  complications  that  arise ;  but  I  may  briefly  state,  that  the 
remedies  which  have  succeeded  best  in  my  hands  are  gentle  aperients  con- 
tinuously used,  tonics,  the  occasional  resort  to  stimulants  and  sedatives 
when  there  is  much  prostration  and  pain,  and  the  persevering  employment 
of  injections,  which  must  often,  at  first,  be  extremely  mild  and  be  aided 
by  blisters.  Perhaps,  however,  the  history  of  a  case  or  two  will  exemplify 
the  rules  of  treatment  better  than  any  description,  and  I  therefore  give 
two ;  one  in  which  the  disposition  to  this  state  seemed  to  be  constitu- 
tional, and  another  in  which  it  appeared  to  have  been  chiefly  induced  by 
large  doses  of  copaiba. 

F.  H ,  Esq.,  a  delicate-looking  man  about  twenty-five  years  old,  who 

had  suffered  a  good  deal  from  spermatorrho3a  and  nervousness,  consulted 
me  in  the  middle  of  August,  1872,  for  what  he  caUed  a  slight  discharge, 
which,  however,  on  examination,  was  evidently  enough  the  beginning  of  a 
pretty  severe  gonorrhoea.  His  account  was  that  he  had  had  it  some  little 
time,  but  had  found  scarcely  any  inconvenience  till  a  few  days  previously, 
when  a  hard  pull  on  the  Thames  and  some  pale  ale  thoroughly  developed 
the  complaint.  As  he  was  of  a  highly  excitable  temperament,  acutely  sus- 
ceptible to  pain,  and  already  depressed  by  long-continued  emissions  and 
great  irritability  of  the  urethra,  I  restricted  the  treatment  almost  entirely 
to  gentle  aperients,  moderate  doses  of  the  acetate  of  potass  mixture  and 
very  mild  injections.  This  treatment  had  nearly  subdued  the  disease, 
14 


210  ON    GONORKHCEA. 

when  he  imprudently  went  down  to  the  sea-side,  took  a  long  walk,  and  in- 
dulged in  other  ways,  the  consequence  of  which  was  an  immediate  and 
severe  relapse.  As  the  gonorrhoea  did  not  seem  now  to  be  influenced  by 
the  same  remedies  as  before,  I  tried  the  santal-wood  oil,  in  doses  of  thirty, 
gradually  raised  to  forty-five  and  then  sixty  minims  a  day,  which  was  as 
much  as  he  could  bear.  At  the  end  of  three  weeks  he  was  no  better  as 
regards  the  discharge,  while  his  health  seemed  to  be  decidedly  worse,  and 
he  was  much  plagued  with  the  emissions.  Tincture  of  the  sesquichloride 
of  iron  in  full  doses  was  ordered,  the  strength  of  the  injections  was  some- 
what increased,  and  a  longer  syringe  was  used.  The  discharge  very  slowly 
diminished,  and  in  order  to  remove  it  thoroughly,  I  applied  the  solid 
nitrate  very  gently  to  the  back  of  the  urethra  and  blistered  the  penis.  These 
steps  brought  on  a  profuse  discharge,  and  great  irritability  of  the  bladder  ; 
but  after  a  few  days  the  symptoms  declined,  and  there  seemed  a  prospect 
of  his  getting  quit  of  his  tormenting  complaint,  when  unfortunately,  one 
evening  early  in  December,  on  alighting  from  a  railway  carriage  while  the 
station  was  in  almost  total  darkness,  he  slipped  and  violently  strained  the 
perineum.  He  immediately  felt  that  he  was  badly  hurt,  and  though  he 
attempted  for  two  or  three  days  to  continue  his  duties,  he  was  obliged  to 
take  to  his  bed. 

I  found  him,  December  14th,  with  an  irregularly  intermittent  pulse, 
coated  tongue,  total  loss  of  appetite,  irritable  bladder,  profuse  urethral 
discharge,  and  great  swelling  of  the  left  testicle,  which  was  also  intensely 
painful  and  sensitive.  His  complexion  was  almost  the  color  of  a  prim- 
rose, his  whole  frame  was  bedewed  with  perspiration,  and  he  seemed 
extremely  agitated  ;  he  was  also  suffering  greatly  from  indigestion  and 
flatulence.  He  was  put  on  a  diet  of  slops,  and  ordered  at  least  three 
glasses  of  port  wine  daily,  with  a  glass  of  hollands  at  bedtime.  Sedatives 
with  stimulants  were  prescribed,  to  be  accompanied  occasionally  by  a 
gentle  aperient ;  but  his  stomach  rejected  every  sedative  that  I  tried,  and 
I  was  compelled  to  give  these  remedies  up.  Under  the  influence,  however, 
of  the  diet  mentioned,  rest,  and  carminatives,  followed  by  nitric  acid  and 
bitters,  his  health  improved  ;  mild  injections  were  given  occasionally 
almost  from  the  first  day,  and  apparently  with  benefit.  The  urine,  which 
at  first  contained  a  surprising  amount  of  urates,  and  a  great  deal  of  mucus, 
had  returned  to  its  normal  state,  the  irritability  of  the  bladder  had  sub- 
sided, and  the  testicle  had  lessened  considerably. 

While  he  was  thus  progressing  he  decided  to  return  to  his  work.  I 
totally  refused  to  sanction  such  a  step,  as  the  weather  was  raw  and  cold. 
In  less  than  a  week,  January  26th,  I  was  again  called  to  him  and  found  a 
complete  relapse.  The  other  testicle  was  swelled  and  very  painful ;  there 
was  great  pain  in  the  perineum  and  bladder  on  making  water  ;  the  pulse 
was  intermittent,  the  tongue  coated,  the  stomach  rejected  food ;  he  was 
sleepless  and  excited,  and  suffered  occasionally  from  headache,  which  was 


TREATMENT.  211 

described  as  "frightful."  Sedatives  were  again  tried,  bimeconate  of 
morphia,  hydrochlorate  of  morphia,  solid  opium,  hyoscyamus  and  chloro- 
dyne  being  ordered  in  succession,  but  none  of  them  agreed  with  him.  The 
same  treatment  as  before  was  therefore  substituted  and  the  injections  were 
resumed,  the  fluid  being  carried  to  the  neck  of  the  bladder.  The  mem- 
branous part  of  the  urethra  was  intensely  sensitive  ;  otherwise  he  bore  the 
injections  very  well.  Having  just  then  received  a  communication  from  a 
patient  in  India,  stating  that  he  had  been  cured  of  an  obstinate  gleet  by 
painting  the  perineum  with  tincture  of  iodine,  and  taking  small  doses  of 
iodide  of  potassium,  I  determined  to  try  these  remedies  in  the  present 
case,  though  I  had,  years  ago,  used  them  several  times  without  any  benefit. 
Here,  too,  they  failed  to  produce  any  impression  on  the  discharge,  and  the 
patient  begged  me  to  desist  from  employing  them,  as  it  seemed  to  him 
sheer  waste  of  time.  The  iodide  was,  however,  continued,  but  in  tolerably 
large  doses  and  in  conjunction  with  the  liquid  potassse  and  bitters,  while 
the  injections  with  the  long  syringe  were  kept  up.  He  rapidly  improved, 
and  on  March  8th  he  returned  to  work,  having  been  for  some  days  quite 
free  from  every  symptom,  except  a  slight  hardening  of  each  epididymis 
and  the  occasional  appearance  of  small  shreds  in  the  urine,  for  which  he 
was  directed  to  pass  a  soft  bougie  twice  a  week.  As  the  nocturnal  emis- 
sions still  plagued  him  occasionally,  I  prescribed  the  tincture  of  the  ses- 
quichloride  of  iron.  On  March  20th  he  called  to  report  that  there  had 
been  no  return  of  the  discharge  and  that  his  health  continued  to  improve. 

In  another  case  the  patient  was  a  member  of  the  medical  profession, 
who  placed  himself  under  my  care,  after  having  made  a  most  unsatisfac- 
tory attempt  to  treat  his  own  complaint. 

I  found  him  low,  weak,  and  dejected  ;  he  was  suffering  under  enlarged 
prostate,  with  a  painful  bearing-down,  as  if  the  rectum  were  coming  out, 
so  that  when  walking  he  constantly  felt  an  urgent  desire  to  keep  his  hand 
pressed  upon  the  anus.  There  was  a  moderate  amount  of  discharge,  with 
no  great  pain  in  making  water  or  during  erections.  The  tongue  was  brown, 
furred,  tremulous,  and  indented  by  the  teeth — the  breath  was  foul — his 
face  looked  coarse  and  dusky — he  said  he  had  lost  all  his  color  along  with 
.  his  appetite  and  strength.  Great  part  of  his  sufferings  he  attributed  to 
the  amount  of  copaiba  he  had  taken  ;  and,  as  according  to  his  own  esti- 
mate, he  had  for  some  time  past  managed  to  get  down  five  ounces  a  week, 
the  supposition  was  very  feasible.  The  use  of  these  preposterous  doses 
was  always  followed  by  nausea  and  loose  stools.  To  complicate  the  case 
still  further,  it  appeared  very  doubtful,  from  the  patient's  description, 
whether  there  was  not  some  stricture  to  be  apprehended,  as  six  years  pre- 
viously he  had  suffered  under  gonorrhoea,  which,  after  having  been  duly 
treated  with  copaiba,  slowly  changed  to  a  gleet,  and  this  in  its  turn  every 
now  and  then  reappeared  ;  so  often,  indeed,  that  I  doubted  if  it  had  ever 
been  cured.  Latterly,  also,  there  had  been  a  good  deal  of  dribbling  after 


212  ON    GONORRHOEA. 

making  water,  and,  the  patient  thought,  some  slight  nan-owing  of  the 
stream.     Patient  intensely  irritable  and  gloomy. 

On  examination  by  the  rectum,  the  prostate  was  found  greatly  enlarged, 
and  a  blister  was  ordered  to  be  applied  to  the  perineum.  A  bougie  was 
also  passed,  and  a  most  irritable  state  of  the  urethra  discovered  ;  no  strict- 
ure, however,  was  encountered.  "Within  forty-eight  hours  after  this 
operation  the  right  testicle  swelled  in  an  extraordinary  way.  The  patient 
could  not  allow  me  to  touch  it,  and  the  attack  was  accompanied  by  such 
prostration  that  he  was  obliged  to  confine  himself  to  his  room.  Morphia 
in  large  quantities  was  ordered,  and  relieved  him  so  rapidly  that  he  said, 
ifhe  could  hardly  describe  the  comfort  this  dreamy,  quiet  state  inspired, 
compared  with  his  first  night's  suffering."  Hot  water  to  the  scrotum  so 
as  almost  to  excoriate  it,  a  well-fitted  suspensory  bandage,  a  brisk  ape- 
rient, and  a  diet  from  which  all  cold,  ascescent,  heavy  articles  of  food 
were  rigidly  excluded,  soon  relieved  all  the  most  severe  symptoms. 

At  the  end  of  a  week  I  examined  the  testicle  ;  and  though  this  was  one 
of  the  worst  cases  of  orchitis  I  ever  saw,  I  was  not  prepared  to  find  such 
evidences  of  active  disease.  The  epididymis  was  greatly  enlarged  and  of  • 
almost  cartilaginous  hardness,  as  was  also  great  part  of  the  testicle ;  and 
though  all  pain  was  gone,  yet  the  patient  still  shrank  instinctively  from  the 
slightest  touch.  I  now  asked  him  if  he  had  ever  strapped  the  testicle  for 
orchitis,  and  if  he  would  like  to  go  through  the  process.  He  at  once  ad- 
mitted that  he  had  performed  the  operation,  but  he  entirely  objected  to 
having,  it  done  on  himself,  and  I  very  strongly  suspect  that  many  advo- 
cates for  strapping  might,  under  similar  circumstances,  give  much  the 
same  reply. 

The  discharge  was  now  treated  with  mild  injections  of  nitrate  of  silver, 
followed  by  the  use  of  gum-elastic  bougies  every  second  day.  Two  blisters 
were  applied  to  the  perineum  and  two  to  the  penis.  Iodide  of  potassium 
was  given  in  doses  of  ten  grains  twice  a  day  ;  calomel  and  black  draught 
twice  a  week.  A  full  meat  diet  was  ordered,  and  a  bottle  of  claret  daily. 

The  discharge  soon  ceased  entirely.  The  urethra  became  so  healthy 
that  the  bougie  could  be  passed  with  scarcely  any  discomfort.  After  the 
first  three  weeks  the  prostate  gave  him  no  further  annoyance  ;  and  finally 
such  a  steady  subsidence  of  the  hardening  of  the  testicle  ensued,  that  when 
he  paid  me  his  last  visit,  about  four  months  from  the  beginning,  little  more 
than  a  slight  thickening  remained  to  mark  the  seat  of  disease.  His  tongue 
became  clear,  moist,  and  firm — his  appetite  returned,  and  he  soon  gained 
flesh  and  strength.  From  having  been  unable  to  walk  a  mile  without  fa- 
tigue, he  was  now  almost  as  well  as  he  ever  had  been,  and  in  better  health 
than  he  had  enjoyed  for  years. 

Another  case  in  which  the  weakness,  partly  natural  and  partly  acquired, 
materially  interfered  with  the  treatment,  will  be  found  in  the  section  on 
strong  tendency  to  stricture. 


TREATMENT.  213 

For  the  most  part  the  weakness  induced  by  long-continued  use  of  co- 
paiba is  easily  remedied.  The  first  step  is,  of  course,  to  give  up  the  use 
of  the  balsam  itself ;  after  this  almost  any  mild  preparation  of  iron,  such 
as  the  citrate,  conjoined  with  some  simple  aperient,  will  soon  remove  the 
effects. 

3.  TENDENCY  TO  INFLAMMATION  or  THE  LACUNAE  OF  THE  UKETHRA. — How- 
ever hazardous  the  statement  may  seem,  that  inflammation  of  the  lacunae 
rarely — perhaps  never — ensues  under  the  use  of  the  treatment  recom- 
mended for  simple  gonorrhoea,  provided  this  has  had  time  to  act  before 
the  lacunae  are  involved,  I  believe  I  am  warranted  in  making  it ;  but 
whether  it  ensues  or  not,  the  treatment  of  the  parent  disorder,  on  the  sys- 
tem mentioned  in  the  foregoing  section,  may  be  safely  pursued,  even 
though  the  previous  experience  of  the  patient  is  that  this  complication  will 
follow. 

A  surgeon,  at  that  time  a  student,  placed  himself  under  the  care  of  Sir 
Astley  Cooper  for  gonorrhoea.  The  great  surgeon  ordered  him  an  injec- 
tion of  nitrate  of  silver,  five  grains  to  an  ounce.  The  inflammation  and 
pain,  however,  became  so  unmanageable  that  he  was  soon  laid  up  with  or- 
chitis  and  abscess  of  the  lacunae.  The  latter  burst  externally,  leaving  a 
fistulous  opening,  which  healed  in  a  few  weeks,  and  a  gleet  which  lasted 
ten  months.  Subsequently  he  had  a  second  attack,  which  healed  in  four 
months  by  means  of  copaiba  and  injections  ;  this  time  also  the  follicles 
suppurated.  He  contracted  a  third  gonorrhoea,  and  treated  it  himself 
with  small  doses  of  copaiba  and  cubebs,  which  purged  and  nauseated  him 
so  much  that  he  was  quite  prostrated.  Dyspepsia  and  total  loss  of  appetite 
came  on,  making  him  so  irritable  and  weak  that  he  could  not  mount  his 
horse  or  attend  properly  to  business  ;  within  a  fortnight  three  of  the  la- 
cunae had  run  into  suppuration  and  one  had  burst  externally.  He  then 
consulted  me.  A  mild  saline  aperient,  with  full  doses  of  morphia  at  night, 
was  ordered,  along  with  sulphate  of  zinc  injections  ;  subsequently  quinine 
and  purgatives  were  given,  and  blue  ointment  was  directed  to  be  rubbed 
over  the  follicles.  He  speedily  improved,  no  more  lacunae  suppurated, 
the  discharge  rapidly  subsided,  and  in  a  few  weeks  gave  way  entirely. 

But  I  have  seen  very  troublesome  results  indeed  where  the  case  was 
treated  differently,  and  I  believe  most  of  the  cases  recorded  of  suppurative 
inflammation  in  the  cellular  tissue  of  this  part  owe  their  origin  to  disease 
beginning  in  the  lacunae. 

E.  E ,  Esq.,  came  under  my  care  for  gonorrhoea.  He  had  been  suf- 
fering under  it  for  several  weeks.  A  small  abscess  had  formed  on  the  right 
side  of  the  penis,  about  two  inches  from  the  mouth  of  the  urethra.  The 
abscess  was  pointing,  and  burst  within  three  days  from  my  first  seeing 
him.  The  urine  began  almost  directly  to  pass  through  the  opening,  and 
continued  to  do  so.  It  was  difficult  to  imagine  any  reason  why  the  patient 
should  suffer  in  this  way.  He  was  a  spare,  strongly  built  man,  of  unusually 


214  ON    GONORRH(EA. 

active,  temperate  habits,  and  extremely  healthy.  He  had  used  no  injec- 
tions and  seemed  to  have  been  treated  principally  with  antiphlogistics  and 
a  few  small  doses  of  copaiba.  While  under  my  care  injections  of  nitrate 
of  silver,  the  solid  nitrate  of  silver,  blisters,  etc.,  were  all  tried  in  vain.  At 
last,  by  applying  the  actual  cautery  and  the  acid  nitrate  of  mercury  to  the 
interior  of  the  fistula,  I  succeeded  in  reducing  it  to  a  very  narrow  passage, 
and,  that  done,  I  speedily  brought  down  the  urethra!  discharge  to  a  mere 
gleet ;  but  I  could  not  completely  cure  either,  and  while  I  was  contem- 
plating further  steps,  the  patient  was  compelled  to  leave  for  a  journey  into 
Russia. 

About  a  year  after  this,  while  still  abroad,  he  again  contracted  a  dis- 
charge, which  seemed  to  have  been  treated  in  much  the  same  way,  except 
that  copaiba  was  given  more  freely,  and,  along  with  it,  cubebs.  As  the  case 
grew  much  worse,  he  set  out  for  England,  but  broke  down  before  he  got 
quite  through  Germany,  and  was  laid  up  for  a  fortnight  with  great  swell- 
ing of  the  penis,  pain,  and  uneasiness  of  the  organs  generally.  Directly  he 
reached  London  he  came  to  see  me.  The  body  of  the  penis  was  consider- 
ably swelled  and  persistently  hard.  In  addition  to  the  old  sinus,  through 
which  the  urine  still  passed,  two  new  ones  had  formed  at  the  junction  of 
the  lower  surface  of  the  penis  and  scrotum.  From  these  radiated  several 
passages  backward  under  the  scrotum,  and  forward  under  the  skin  of  the 
penis,  and  though  the  probe  could  not  be  introduced  into  the  urethra,  the 
dribbling  through  these  sinuses,  every  time  the  patient  made  water,  showed 
that  there  was  a  communication  between  them  and  the  canal 

For  several  weeks  I  tried  everything  I  could  think  of  to  heal  these  fistu- 
lae.  Dilatation  of  the  openings,  the  application  of  the  acid  nitrate  of  mer- 
cury, of  the  actual  cautery,  and  of  a  strong  solution  of  canthao-adin  in  glacial 
acetic  acid,  were  repeatedly  used,  but  to  no  purpose ;  while  the  gonoiThcea 
remained  unaffected  by  blisters,  injections,  and  the  use  of  the  solid  nitrate 
to  the  interior  of  the  canal.  The  thickening  and  induration  of  the  penis 
and  scrotum  got  worse,  and  the  sinuses  evidently  increased  in  extent ; 
some  of  the  skin,  too,  on  the  lower  part  of  the  penis  was  on  the  point  of 
sloughing.  At  last,  in  a  consultation  with  my  friend,  Mr.  T.  Carr  Jackson, 
it  was  decided  to  put  the  patient  under  chloroform  and  lay  open  the  si- 
nuses. This  was  done  with  the  result  of  laying  bare  five  fistulous  openings 
into  the  urethra,  and  such  a  mesh  of  burrowing  passages  as  has  seldom,  I 
fancy,  been  paralleled.  Mr.  Jackson  said  he  had  never  seen  anything  like 
it  I  was  compelled  to  remove  some  of  the  skin  of  the  penis,  its  vitality 
being  so  compromised  that  there  was  no  chance  of  saving  it.  Some  weeks 
after  the  patient  again  left  England,  at  which  time  not  one  of  the  openings 
into  the  urethra  had  healed.  He  subsequently  wrote,  however,  from  East 
India  to  say  that  he  was  a  great  deal  better. ' 

1  Mr.  Johnson  had  also  a  patient  tinder  his  care  who  had  gonorrhoea  several  times, 
and  on  almost  all  occasions  the  lacunae  suffered  more  or  less.  Op.  citat.,  p.  183. 


TREATMENT.  215 

Mr.  Phillips  seems  to  have  been  as  fortunate  here  as  in  stricture.  "  I 
have,"  he  says,1  speaking  of  this  complication,  "adopted  a  treatment  from 
which  I  have  experienced  the  greatest  success.  I  apply  the  lunar  caustic 
to  that  portion  of  the  urethra  in  which  the  interior  orifice  of  the  fistula  is 
situated."  The  reader  has  just  seen  with  what  success  I  applied  it,  and  I 
repeatedly  touched  not  only  the  orifices,  but  also  the  sinuses  themselves 
and  adjoining  parts  of  the  urethra. 

Mr.  Lee,  as  I  understand  him,  thinks  that  these  abscesses  begin  in  the 
areolar  tissue  surrounding  the  urethra,  and  this  view  is  supported  by  the 
observations  of  M.  Lagneau,  fils,"  who,  speaking  of  three  cases,  in  two  of 
which  the  purulent  collection  was  seated  near  the  frsenum,  and  in  one  just 
before  the  scrotum,  considers  the  peri-urethral  tissue  most  likely  to  be 
their  seat,  because  they  did  not  impede  the  passage  of  the  urine,  projected 
outward,  and  opened  exclusively  on  the  outer  surface  ;  grounds  which  do 
not  seem  to  me  conclusive,  as  closing  of  their  urethra!  orifices  and  disten- 
tion  are  not  essential  steps  in  the  process. 

4  MORBID  SENSIBILITY  OF  THE  URETHRA. — In  excessive  natural  tenderness 
of  the  urethra  it  is  sometimes  necessary  to  wait  a  day  or  two  in  order  that 
the  action  of  the  potass 3  may  be  set  up,  and  to  give  a  sedative  every  night, 
before  beginning  with  injections.  The  first  two  or  three  of  these  may  con- 
sist of  warm  water ;  the  next  of  weak  solution  of  nitrate  of  silver,  begin- 
ning in  some  persons  as  low  as  one-tenth  of  a  grain  to  an  ounce  ;  after  this 
no  farther  precaution  is  necessary.  "Where  this  extreme  sensibility  seems 
dependent  upon  rheumatism  or  gout,  a  grain  of  the  extract  of  colchicum 
every  night  may  be  serviceable.  I  speak  doubtfully,  however,  and  more 
out  of  deference  to  tradition  than  as  the  result  of  experience,  for  I  myself 
never  saw  the  least  good  from  the  practice. 

In  most  cases,  after  this  difficulty  is  overcome,  the  injection  may  be  in- 
creased in  strength  as  with  other  patients  ;  but,  on  the  other  hand,  there 
are  many  persons  who  can  never  bear  injections  stronger  than  a  grain 
to  the  ounce  without  feeling  severe  pain.  One  gentleman,  under  my  care, 
complained  of  much  uneasiness,  lasting  for  several  hours,  with  heat  and 
swelling  of  the  penis,  from  a  solution  of  two-thirds  of  a  grain  to  the  ounce, 
and  noticed  these  symptoms  very  perceptibly  when  the  strength  was  reduced 
to  the  eighth  of  a  grain.  Now  it  is  never  necessary  to  give  severe  pain.  If 
the  patient  is  only  seen  when  the  gonorrhoea  itself  is  declining  in  violence, 
I  would  recommend  free  bathing  of  the  penis  with  hot  water  two  or  three 
times  a  day ;  the  application  of  veratrin  ointment,  five  grains  to  half  an 
ounce,  to  the  under  surface  of  the  urethra ;  and  the  use  of  gum-elastic 
bougie. 

In  some  cases  of  acquired  morbid  sensibility  of  the  urethra  behind  a 
stricture,  both  of  them  the  sequelae  of  gonorrhoea,  the  nitrate  gives  ease 

1  Op.  citat.,  p.  289.          s  Gazette  Hebdomadaire,  p.  343.     1862.          3See  p.  124. 


216  ON    GONOEKHCEA. 

where  the  most  delicate  touch  of  the  bougie  is  not  borne.  I  had  under  my 
care  a  case  thus  originated,  where  I  was  for  some  time  entirely  foiled.  The 
patient  suffered  little  discomfort  from  the  application  of  caustic  to  the 
stricture,  and  he  scarcely  complained  at  all  when  I  expanded  the  contraction 
with  a  straight  screw  dilator  which  I  use  ;  but,  though  a  'resolute  man,  he 
always  shrank  so  from  the  contact  of  the  point  of  the  instrument,  and  even 
of  the  softest  bougie,  with  the  urethra  behind  the  stricture,  that  I  was 
obliged  to  desist.  At  last  I  passed  the  nitrate  right  through  the  stricture 
to  this  tender  spot  and  used  it  pretty  freely.  The  patient  suffered  little 
more  than  from  the  bougie,  while  the  abnormal  sensitiveness  was  so  com- 
pletely removed  that,  though  I  employed  both  dilator  and  bougie  on  sev- 
eral subsequent  occasions,  he  never  complained.  The  instrument  for  ap- 
plying the  nitrate  in  this  way,  as  also  that  used  for  stricture,  will  be  de- 
scribed in  the  next  section. 

5.  STRONG  TENDENCY  TO  STRICTURE — that  is,  where  the  canal  begins  to 
contract  within  a  very  short  time  after  the  first  appearance  of  gonorrhoea — 
though  not  very  uncommon  when  this  disorder  is  neglected,  has  only  oc- 
curred in  my  experience  three  times  in  cases  treated  properly  with  potass 
and  injections.  In  two  of  them  it  yielded  quickly  enough  to  the  solid  nitrate 
applied  by  means  of  the  sheath  and  stylet  to  be  presently  described.  In 
the  third  case  the  patient,  quite  a  lad,  with  a  first  and  pretty  sharp  gonor- 
rhoea, was  suddenly  despatched  on  business  which  enabled  him  to  indulge 
in  the  pleasures  of  the  table  to  any  extent  he  liked.  Not  having  enjoyed 
such  a  privilege  before,  he  made  the  best  use  of  it  now — lived  on  game, 
salmon,  champagne,  punch,  etc.,  and  returned  to  London  with  the  urethra 
closely  strictured  for  about  two  inches — a  state  of  matters  which  required 
about  eight  months  to  set  right  again. 

A  slighter  degree  of  this  disposition  may,  when  accompanied  by  great  con- 
stitutional weakness  and  impaired  health,  also  give  a  great  deal  of  trouble. 

C.  F ,  Esq.,  a  thin,  extremely  delicate-looking  man  about  twenty- 
seven  years  old,  consulted  me  March,  1874.  His  account  was  that  he  had 
inherited  a  very  feeble  and  excitable  constitution,  with  a  morbid  dread  of 
pain,  and  that  he  had  resided  a  considerable  time  in  Jamaica,  where  he  had 
contracted  intermittent  fever,  from  the  effects  of  which  he  had  never  re- 
covered. Some  considerable  time  before  his  visit  to  me  he  had  been 
infected  with  gonorrhoea,  which,  though  never  severe,  and  treated  by  his 
medical  attendant  with  great  care  and  skill,  had  lasted  six  months.  Al- 
though the  discharge  had  ceased  there  was  a  sensation  of  tenderness  and 
uneasiness  in  the  posterior  part  of  the  urethra,  which  showed  something 
was  not  quite  right,  and  it  was  for  this  that  he  came  to  me.  I  advised 
him  to  pass  a  bougie  once  a  week  and  to  take  a  tonic,  but  he  neglected 
to  do  either,  and  I  saw  no  more  of  him  till  the  beginning  of  June,  when 
he  came  to  be  treated  for  a  rather  active  gonorrhoea  which  he  had  caught 
quite  recently. 


TREATMENT.  217 

He  was  put  on  preparations  of  potass  and  gentle  aperients,  but,  owing 
to  his  excessive  dread  of  pain,  I  had  great  difficulty  in  gaining  his  assent 
to  anything  in  the  shape  of  injections.  He  was  imbued  with  an  utter  horror 
of  even  the  slightest  operation.  Vaccination,  he  said,  had  made  him  faint. 
However,  after  a  little  while  I  succeeded  in  carrying  the  point,  with  many 
stipulations  on  his  part  that  the  injections  should  be  very  mild,  and  that 
the  point  of  the  syringe  should  only  just  enter  the  urethra,  the  latter  con- 
dition being  one  which  I  took  the  first  opportunity  of  evading.  The  dis- 
charge was  gradually  brought  down  to  a  very  slight  affair,  and  then  the  im- 
provement came  to  a  stand-still.  I  now  tried  thelsandal-wood  oil,  which  the 
patient  took  with  great  regularity  in  quite  half-drachm  doses  three  times  a 
day  for  some  time.  He  was  most  anxious  to  get  well,  and  I  believe  implic- 
itly followed  out  every  direction  given  him.  The  oil  seemed  to  produce 
some  improvement,  and  then  there  was  a  relapse  and  another  stand-still. 
As  he  was  extremely  low,  with  a  weak,  small  pulse,  I  did  not  much  like 
going  on  with  the  medicine  and  prescribed  him  quinine,  followed  by  steel, 
with  blistering.  This,  however,  effected  no  particular  good  as  regarded 
the  discharge,  which  did  not  get  quite  well 

From  the  beginning  I  had  warned  the  patient  that  the  stricture,  which 
I  fancied  was  springing  up  in  consequence  of  the  first  gonorrhoea,  would 
be  aggravated  by  the  present  attack,  and  when  I  saw  that  the  means  em- 
ployed were  not  bringing  about  'a  cure,  I  advised  him  not  to  waste  any 
further  time  upon  them,  but  to  let  me  pass  a  bougie.  Of  this  he  would 
not  hear  unless  he  was  put  under  chloroform,  to  which  I  most  reluctantly 
consented,  and  he  was  accordingly  chloroformed  four  times.  He  was  how- 
ever so  refractory,  declaring  he  should  die  if  his  hands  were  held,  and 
then,  when  they  were  set  free,  snatching  the  inhaler  from  his  mouth,  that 
three  times  no  real  insensibility  was  produced,  and  he  foiled  all  attempts 
to  explore  the  urethra.  Once  only  he  was  fairly  brought  under  the  in- 
fluence of  the  anaesthetic,  and  then  the  insensibility  became  so  great,  that 
the  surgeon  who  gave  the  chloroform  grew  alarmed,  and  I  could  do  no 
more  than  satisfy  myself  that  there  was  some  contraction  about  five  and  a 
half  inches  down,  a  number,  six  passing  with  moderate  ease. 

As  chloroform  was  of  no  use,  he  was  put  under  laughing-gas.  I  then 
passed  down  an  armed  number  eight  bougie,  and  as  it  would  not  go 
through  the  contraction  just  spoken  of,  pressed  it  sufficiently  long  against 
the  narrowed  spot  to  act  thoroughly.  The  patient  suffered  very  little  after- 
pain,  but  the  discharge  remained  as  before.  The  sandal- wood  oil  was  again 
tried,  in  as  large  doses  as  his  stomach  could  bear,  and  again  failed.  He 
also  took  matico,  in  which  he  had  great  faith,  with  as  little  effect.1  As  he 
still  shrank  from  the  only  step  likely  to  be  of  service,  the  use  of  the  bougie, 
except  under  chloroform,  which  I  refused  to  employ,  I  advised  him  to  blister 

1  See  page  83. 


218  ON    GONORRHOEA. 

again,  and  to  accept  an  invitation  sent  him  to  spend  a  few  weeks  at  the 
sea-side.  He  went  down  and,  while  there,  blistered  four  or  five  times,  he 
could  not  exactly  recollect  which.  His  health  improved  considerably  from 
the  change  of  air,  and  an  impending  attack  of  intermittent  fever  passed  off ; 
but  the  discharge  continued  so  entirely  unaffected,  that  at  last  he  made  up 
his  mind  to  have  the  bougie  used,  which,  however,  owing  to  my  own  ab- 
sence from  town,  could  not  be  begun  until  near  the  end  of  October.  Mean- 
while I  directed  him  to  give  up  the  dilute  phosphoric  acid,  which  had  been 
ordered  for  the  symptoms  of  fever,  and  to  take,  instead  of  it,  the  tincture 
of  sesquichloride  of  iron,  ^hich  he  did,  and  reported,  when  I  next  saw  him, 
that  he  had  gained  both  flesh  and  strength  from  the  use  of  the  latter. 

On  my  return  from  London  the  employment  of  the  bougie  was  com- 
menced, and  with  this  began  the  first  real  improvement  in  the  case.  The 
stricture  yielded  slowly  but  steadily,  and  directly  this  change  showed 
itself  the  discharge  lessened.  At  first  there  was  always  some  slight  bleed- 
ing after  even  the  most  gentle  passing  of  the  instrument,  but  this  was  soon 
checked  by  the  internal  use  of  tannin.  The  patient  had  at  one  time  suf- 
fered, though  not  very  badly,  from  chordee,  the  annoyance  being  rather 
persistent  than  severe,  and  this  the  bougie  only  relieved  slowly.  By  the 
end  of  the  third  week  of  December  the  discharge  was  practically  extinct, 
and  the  urethra  dilated  to  its  natural  size.  During  the  first  few  days  of 
the  sudden  thaw  which  took  place  in  the  beginning  of  January,  there  was 
an  apparent  relapse,  possibly  due  to  the  patient  having  caught  a  bad  cold, 
but  the  discharge  was  different  from  what  I  had  ever  seen  it  in  him,  being 
thin,  not  a$  all  viscid,  and  of  a  pale,  dirty  yellow.  I  pronounced  it  not  to 
be  gonorrhoeal,  and  under  the  use  of  a  drachm  of  tannin  daily  it  went  away 
almost  as  fast  as  it  came.  On  the  25th  of  March  he  reported  that,  for 
thirty-seven  days  he  had  not  perceived  a  speck  of  discharge  in  the  urine, 
which  he  always  scrupulously  examined  at  least  once  daily. 

During  the  whole  time  the  patient  was  under  my  care  I  believe  he 
never  omitted  to  take  a  single  dose  of  the  medicine  ordered  for  him,  nor 
had  I  ever  reason  to  suspect  that  he  transgressed  against  the  suggestions 
made  to  him  about  remaining  quiet  and  abstaining  from  stimulants  ;  yet 
the  disease  lasted  nearly  seven  months.  Possibly  the  stricture  was  the 
chief  cause  of  this  persistence,  but  his  morbid  dread  of  pain  was  the  cause 
of  the  stricture  remaining  so  long  unrelieved,  and  his  first  attack,  with 
which  stricture  had  nothing  to  do,  lasted  six  months. 

Caustic-holders. — The  instrument '  just  spoken  of  and  displayed  in  the 
engraving  consists  (1)  of  a  platinum  or  silver  canula,  A,  shaped  like  a  No. 
9  catheter  with  the  blunt  end  cut  off,  and  a  pea-headed  stylet,  B.  It  ia 
passed  down,  with  the  stylet  in,  to  any  part  of  the  urethra  that  seems  very 

1  The  larger  instrument  is  reduced  almost  one-half,  the  smaller  one  a  fourth.  The 
drawing  of  the  ladle  is  of  the  actual  size.  The  instruments  are  made  by  Messrs.  Wal- 
ters &  Co. ,  Moorgate  Street. 


TREATMENT. 


219 


tender,  and  the  stylet  being  withdrawn,  a  small  flexible  bougie,  armed  by 
dipping  the  tip  into  caustic  fused  in  the  ladle,  Z>,  is  introduced  through 
the  canula  and  drawn  lightly  over  the  urethra  for  an  inch  or  two.  It  is 


then  drawn  back  within  the  stylet  while  the  instrument  is  removed,  so  that 
only  the  part  the  surgeon  wishes  to  cauterize  is  brought  into  contact  with 


220  ON    GONORRH(EA. 

the  nitrate.  C  represents  a  smaller  instrument  of  the  same  kind  sheathed, 
to  be  used  when  the  seat  of  morbid  action  is  nearer  the  mouth  of  the  ure- 
thra. 

I  have,  however,  after  many  failures,  devised  an  instrument  which  I 
think  I  may  safely  speak  of  as  superior  to  that  just  described,  so  far  as  re- 
gards applying  the  nitrate  to  the  walls  of  the  urethra  in  morbid  sensibility 
of  the  passage,  gleet,  etc.  It  does  not  in  any  way  supersede  the  sheath 
and  stylet  in  stricture,  and  indeed  aims  at  a  different  object. 

The  instrument  consists  of  a  soft  gum-elastic  bougie,  into  which  is  in- 
serted, two  inches  from  the  tip,  a  platinum  cage,  soldered  with  gold  so  as 
to  resist  the  action  of  the  nitrate.  This  cage  is  an  inch  long,  and  some- 
what less  in  diameter  than  the  part  of  the  bougie  into  which  it  is  inserted, 
an  arrangement  which  affords  greater  protection  to  the  nitrate,  and  the 
material  in  which  it  is  imbedded,  while  the  instrument  is  passing  along  the 
urethra,  at  the  same  time  that  it  allows  the  salt  to  flow  out  when  melted. 
It  (the  cage)  consists  simply  of  four  slips  of  platinum  let  into  a  ring  of  the 
same  metal  at  each  end.  Though  the  construction  appears  slight,  it  is 
really  possessed  of  great  strength,  a  wire  being  continued  from  the  cage 
over  the  tip  of  the  bougie. 

It  is  charged  as  follows.  In  summer  a  piece  of  white  wax,  as  big  as  a 
small  pea,  is  put  into  a  Berlin  crucible,  and  melted  with  a  gentle  heat  over 
a  spirit  lamp.  To  this,  when  melted,  is  added  twice  the  bulk  of  cacao 
butter,  which  at  once  mixes  with  the  wax.  So  soon  as  this  has  set,  the 
surgeon  takes  a  piece  big  enough  to  fill  the  space  between  the  bars  of  the 
cage  and  squeezes  it  in.  Then,  with  a  penknife,  he  scoops  out  a  groove 
in  the  wax  and  butter,  more  than  large  enough  to  hold  the  amount  of 
nitrate  he  intends  to  use,  which  may  be  half  a  grain  to  a  grain.  This 
being  placed  in  the  groove,  any  space  left  is  filled  up  with  a  little  wax  and 
"butter  melted  for  the  purpose,  and  any  loose  or  projecting  points  left  are 
scraped  off  with  the  penknife,  or  rubbed  down  with  the  fingers.  In  win- 
ter less  wax  must  be  used,  and  in  very  cold  weather  it  may  be  dispensed 
with  altogether. 

The  surgeon,  having  first  of  all  passed  a  gum-elastic  bougie  a  size 
larger  than  the  instrument  I  have  been  describing,  with  the  idea  of  finding 
out  whether  the  passage  is  clear  up  to  the  part  where  he  intends  to  apply 
the  caustic,  as  also  whether  there  are  any  tender  spots  on  the  way,  with- 
draws the  bougie  and  introduces  the  caustic-holder,  well  oiled,  sliding  it 
along  as  quickly  as  he  can,  till  the  cage  is  brought  opposite  the  irritable 
part.  Having  now  introduced  the  instrument,  the  surgeon  allows  it  to 
remain  till  the  patient  begins  to  complain  of  a  burning  sensation,  when  it 
may  at  once  be  withdrawn.  With  management  there  should  not  be  any- 
thing like  severe  pain,  but  if  by  chance  this  be  set  up,  the  use  of  a  hot 
bath  at  98°  or  100°  Fahr.  for  two  or  three  minutes,  and  a  good  sedative, 
such  as  a  dose  of  Battley's  solution  in  an  ounce  of  the  brandy  mixture  of 


TREATMENT.  221 

the  pharmacopoeia,  will  generally  relieve  it  in  a  short  time.  Or,  instead  of 
a  bath,  the  patient  may  bathe  the  perineum  well  with  hot  water,  but  this,  if 
more  convenient,  is  less  efficacious.  In  my  own  practice  I  have  rarely 
known  either  called  for.  Sometimes  a  little  purulent  discharge,  or  a  slight 
degree  of  bleeding,  follows  even  a  very  gentle  application  of  the  caustic, 
but  the  surgeon  may  quite  safely  leave  this  to  itself,  and  repeat  the  appli- 
cation from  two  or  three  to  several  times,  as  the  case  is  more  or  less 
severe.  If  there  be  no  particular  tenderness,  the  caustic  may  be  applied 
to  the  prostatic  portion  of  the  urethra. 

•The  advantages  offered  by  this  instrument  are,  its  small  cost,  which  is 
not  more  than  half  that  charged  for  other  caustic-holders  ;  its  simplicity, 
all  screws,  stylets,  etc.,  being  done  away  with  ;  its  safety,  the  strength  of 
the  materials  being  so  great  that  a  strong  man  could  not  drag  them  asun- 
der, while  they  are  not  acted  on  by  the  nitrate  as  in  Lallemand's  instru- 
ment ;  and  finally,  the  ease  with  which  it  can,  owing  to  its  softness  and 
elasticity,  be  introduced  even  into  a  very  sensitive  urethra. 

6.  RETENTION  OF  URINE. — This  complication  may  very  well  be  taken 
here,  though  really  its  more  natural  place  would  be  in  the  preceding 
chapter,  as  it  belongs  to  those  things  'which  do  not,  materially  at  least, 
interfere  with  the  treatment  of  the  gonorrhoea.  I  have  not  often  seen  it 
except  in  the  case  of  a  patient  who,  with  a  previously  existing  stricture 
from  gonorrhoea,  had  contracted  a  fresh  attack  of  the  latter  disease  ;  in 
these  instances,  too,  the  immediate  attack  of  spasmodic  stricture  has 
generally  been  traced  to  a  debauch,  though  sometimes  it  arises  from  long 
exposure  to  cold  and  wet,  one  of  the  worst  cases  I  ever  saw  following  upon 
a  walk  of  some  hours  through  a  snow  storm.  One  patient,  not  suffering 
previously  from  stricture,  brought  on  the  contraction  at  the  very  outset  of 
the  gonorrhoea  by  passing  a  bougie  four  times  in  one  day,  setting  up  a 
degree  of  spasm  which  took  four  or  five  months  to  overcome.  In  addition 
to  this  M.  Mauriac  recognizes '  a  progressive  and  incomplete  retention, 
generally  due  to  the  inflammation  having  reached  the  membranous  or 
prostatic  urethra,  seen  usually  in  irritable  subjects,  persons  suffering  from 
catarrhal  "  urethrorrhcea,"  contracted  by  connection  with  the  female  just 
before  or  after  the  menstrual  period,  a  complaint  with  which  I  am  not 
familiar. 

Treatment. — When  such  a  thing  can  be  procured  the  patient  should  at 
once  take  a  hot  bath,  quite  100° — higher  if  he  can  bear  it.  Very  often  this 
will  suffice,  and  it  almost  always  affords  some  help,  but  it  should  be  accom- 
panied by  a  full  dose  of  laudanum  or  Battley's  sedative  ;  and  unless  this 
speedily  overcomes  the  obstruction  the  catheter  should  at  once  be  resorted 
to.  On  the  whole  no  instrument  has  answered  so  well  in  my  hands  as  a 
moderate-sized  or  small  gum-elastic  catheter,  which  I  almost  invariably 

1  Progr£s  Medical.     Quoted  in  London  Medical  Record,  p.  335.     1880. 


222  ON    GONORRHOEA. 

use  without  a  stylet.  Mr.  Savory  strongly  praises '  chloroform  in  spasmodic 
stricture  ;  he  also  remarks  that  the  action  of  a  brisk  aperient  will  often 
cause  a  passage  of  urine. 

Sometimes  a  gonorrhcea  supervenes  upon  an  old  stricture.  The  gonor- 
rhoea is  cured  or  reduced  to  a  slight  gleet,  but  so  soon  as  ever  a  bougie  is 
passed  to  remove  the  stricture  the  discharge  returns.  I  have  tried  pretty 
well  every  variety  of  treatment,  and  consider  on  the  whole  that  embodied 
in  the  following  paragraph  as  the  most  satisfactory. 

7.  BALANITIS  OCCURRING  ALONG  WITH  PHTMOSIS  AND  STRICTURE. — If  there  be, 
along  with  the  state  of  matters  just  described,  balanitis  and  phimosis,  the 
prepuce  should  forthwith  be  divided,  unless  the  patient  will  permit  of 
circumcision  being  performed,  which  is  still  more   effectual.     This  step 
speedily  disposes  of  both  the  latter  complications,  the  balanitis  requiring 
little,  if  any  treatment  after  the  operation  has  been  performed.     The  next 
thing  is  to  reduce  the  gonorrhcea  to  a  minimum,  for  according  to  my  expe- 
rience it  is  rarely  cured  at  this  stage,  by  means  of  very  mild  injections  of 
nitrate  of  silver.     So  soon  as  ever  this  is  done  the  solid  nitrate  should  be 
applied  to  the  stricture,  and  nothing  further  need  be  attempted  till  this 
is  set  right.     With  the  removal  of  it,  the  gonorrhcea  I  believe  invariably 
disappears  of  itself.     The  bougie  may  be  tried  instead  of  the  nitrate,  but 
my  essays  with  it  in  such  cases  have  been  unsatisfactory,  whereas  it  is 
scarcely  exaggerating  to  say  that  the  nitrate,  though  applied  only  to  the 
contraction,  acts  with  almost  unfailing  certainty  on  the  whole  seat  of  the 
running. 

8.  EXCESSIVE  IRRITABILITY  OF  THE  BLADDER. — Sudden  and  almost  irresist- 
ible irritability  oceurs  at  times  in  very  healthy  persons,  often  when  the 
gonorrhcea  is  yielding  to  the  influence  of  medicines ;  but  there  is  also 
an  extreme  and  rare  form  which  is  encountered  in  delicate  persons,  and 
appears  to  arise  from  the  gonorrhea  al  inflammation  extending  back  within 
the  first  few  days  of  its  existence  to  the  bladder.     It  is  sometimes  accom- 
panied by  a  strong  tendency  to  evacuate  the  bowels  on  administering  a 
urethral  injection. 

Notwithstanding  all  my  attempts,  I  have  failed  to  discover  any  remedy 
on  which  we  can  rely  in  this  variety  of  irritable  bladder,  which,  however, 
is  not  often  met  with.  I  have  tried  every  means  recommended  in  standard 
works  for  the  form  usually  seen,  along  with  most  of  our  sedatives  and 
antispasmodics,  such  as  sumbul,  chloroform,  etc.,  with  no  good  result. 
On  the  contrary,  I  found  the  ordinary  remedies  so  injurious  here  that  I 
soon  abandoned  them  in  favor  of  tonics  (using  mild  sedatives  merely  as 
an  aid),  an  antacid  purgative,  such  as  a  dose  of  Henry's  magnesia  or  the 
effervescing  citrate,  and  the  steady  use  of  injections.  The  following  his- 
tory will,  I  hope,  exemplify  this  class  of  cases  better  than  any  formal 
description  : 

1  St.  Bartholomew's  Hospital  Reports,  p.  29.     1868. 


TREATMENT.  223 

A  gentleman  engaged  in  speculations  of  a  very  hazardous  nature,  and 
subject  in  consequence  to  all  the  variations  between  the  extremes  of  excite- 
ment and  depression,  consulted  me  respecting  a  gonorrhoea  which  he  had 
just  contracted.  As  he  seemed  very  irritable  and  nervous  I  inquired  into 
his  history,  and  found  that,  after  having  been  long  in  indifferent  health, 
he  had  two  years  before  been  attacked  with  influenza,  for  which  he  placed 
himself  under  the  care  of  a  well-known  physician. 

The  disorder  slowly  gave  way,  but  he  had  never  regained  his  flesh  and 
strength  ;  his  digestion  was  impaired,  his  appetite  capricious,  bowels  often 
costive,  urine  loaded  with  phosphates  and  mucus,  tongue  coated  and  marked 
by  the  teeth.  He  was  haunted  by  a  feeling  that  he  was  growing  smaller, 
which,  he  said,  in  spite  of  its  absurdity,  he  could  not  shake  off.  The  dis- 
charge from  the  urethra  was  thin,  yellow,  and  profuse,  much  like  that 
occasionally  seen  without  any  manifest  cause  in  elderly  men.  There  was 
no  particular  uneasiness  about  the  parts  of  generation ;  no  pain  in  making 
water,  chordee,  or  swelling  of  the  prepuce.  The  discharge  had  appeared 
only  two  days  previously. 

A  mild  saline  aperient  was  ordered,  and,  as  the  patient  was  very  timid, 
only  a  weak  injection  was  employed.  In  a  few  days  the  irritability  of  the 
bladder  became  so  excessive  that  the  injection  was  instantly  thrown  out 
again  with  a  little  urine,  and  the  patient  had  to  make  water  three  times  in 
the  first  half  hour  after.  This  state  continued  to  a  certain  extent  up  to 
a  late  hour  in  the  evening.  He  was  ordered  meat  and  a  glass  of  port  daily, 
quinine  and  sedatives  were  given',  and  as  it  was  found  that  the  occasional 
use  of  brisk  cathartics  induced  much  less  irritability  of  the  bladder  and 
rectum  than  the  mild  aperients  had  done,  they  were  substituted.  Injec- 
tions of  nitrate  of  silver,  however,  were  principally  relied  on  to  remove 
the  discharge. 

The  first  effect  of  these  was  to  increase  the  irritability  of  the  bladder 
for  an  hour  or  two  after  using  them,  when  it  quickly  ceased  and  did  not 
return  till  the  injection  was  repeated  the  next  day.  Having  syringed  out 
the  anterior  part  of  the  urethra,  the  tube  of  the  long  syringe  was  passed 
down,  and  when  withdrawn  pus  was  found  adhering  to  its  point.  The 
long  syringe  was  therefore  substituted  for  the  short  one,  and  the  injection 
was  gradually  raised  to  the  strength  of  ten  grains  to  an  ounce ;  an  amount 
I  have  often  found  necessary  whenever  it  was  requisite  to  apply  injections 
low  down.  This  alteration  had  the  desired  effect ;  the  discharge  dimin- 
ished steadily,  though  it  did  not  entirely  disappear  for  six  weeks.  The 
irritability  of  the  bladder  grew  gradually  less,  but  to  the  very  last  the  pa- 
tient was  always  compelled  to  sit  down  immediately  after  an  injection  ; 
and  hence  as  the  remedy  was  continued  occasionally  for  some  weeks  after, 
it  may  be  assumed  that  the  irritability  endured,  in  all,  full  ten  weeks  in  a 
rather  severe  form.  There  was  no  relapse,  the  patient  gained  flesh  and 
strength  under  the  use  of  quinine,  and  married  soon  after. 


224  ON    GONOERHCEA. 

9.  INFLAMMATION  or    THE   BLADDER. — This  rare  complication,  when   it 
does  happen,  generally  attacks  the  neck  of  the  viscus,  but  whatever  be  the 
part  assailed,  it  should,  I  think,  be  treated  in  the  same  way.     The  prompt 
and  liberal  use  of  sedatives,  hot  bathing,  the  application  for  a  short  time 
of  a  hot  turpentine  stupe  over  the  pubis,  and  a  diet  of  slops,  from  which 
wine  is  not  necessarily  excluded,  are  the  most  suitable  of  the  means  with 
which  I  am  acquainted.     Any  direct  applications  are,  I  think,  even  when 
the  more  formidable  symptoms  have  abated  and  the  affection  seems  enter- 
ing upon  a  chronic  state,  better  suspended.     As  a  rule,  the  symptoms  al- 
most invariably,  if  not  in  every  case,  decline  under  the  influence  of  these 
measures,  and  those  recommended  for  irritability  of  the  organ.     The  em- 
ployment, too,  of  some  of  the  substances  of  which  the  injections,  recom- 
mended by  certain  authors  for  this  symptom,  are  composed,  seems  to  me 
as  much  calculated  to  endanger  the  patient's  life  as  to  cut  short  the  course 
of  the  disorder.     M.  Robert  mentions '  most  serious  results  as  having 
arisen  from  an  injection  of  cold  tar- water.     A  case  of  acute  cystitis  from 
gonorrhoea,  treated  with  "balsams"  and  Van  Swieten's  fluid,   ending  fa- 
tally, in  the  practice  of  M.  Guilvac,  is  mentioned  in  the  Giornale  italiano? 
After  death  it  was  found  that  perforation  of  the  bladder  had  taken  place. 
Brodie  says  *  that  when,  in  acute  inflammation  of  the  bladder,  the  urine 
remains  acid,  and  the  sediment  which  it  deposits  is  yellowish,  having  no 
adhesive  property  and  being  apparently  purulent,  the  patient  will  often 
derive  benefit  from  two  grains  of  calomel  and  half  a  grain  of  opium  two 
or  three  times  a  day  ;  when  it  is  alkaline,  he  has  known  much  good  arise 
from  the  use  of  vinum  colchici,  fifteen  to  twenty  minims  three  times  daily, 
for  three  or  four  successive  days. 

10.  EXCESSIVE  IRRITABILITY  OF  THE  RECTUM  seems  principally  due  to  the 
sudden  and  irregular  distention  of  the  urethra  by  the  injection.     I  in- 
jected a  gentleman  with  solution  of  nitrate  of  silver  for  a  gleet  which  had 
been  treated  with  chloride  of  zinc  injection  and  copaiba  ;  he  was  compelled 
to  make  a  precipitate  retreat  to  the  water-closet.     The  next  day  I  made 
the  injection  quite  weak,  although  the  first  had  occasioned  no  great  pain  ; 
the  irritability  of  the  rectum  was  still  as  great.     I  then  used  the  caustic 
plug  described  at  page  134;  this  did  not  induce  any  irritability  of  the  rec- 
tum, and  four  applications  removed  the  discharge.     It  came  back  a  little, 
and  he  never  summoned  up  resolution  again,  saying  that  "  for  a  mere 
drop  of  discharge  it  was  not  worth  the  trouble." 

11.  PERINEAL  ABSCESS. — Of  gonorrhoea  accompanied  by  this  complication 
I  cannot  give  so  favorable  an  account,  not  having  found  it  so  amenable  to 
treatment  as  might  have  been  expected.     Fortunately  enough,  it  is  rather 
rare. 

'Op.  citat.,  p.  91. 

9  An.  viii.,  p  302.     1873.     Quoted  from  the  Bordeaux  Medical. 

1  Works,  vol.  ii.,  p.  463. 


TREATMENT.  225 

It  is  laid  down  as  a  rule  of  treatment  that  leeches,  antimony,  calomel, 
and  black  draught  should  be  exhibited  for  this  affection.  Those  who  have 
succeeded,  with  these  remedies,  in  checking  the  progress  of  perineal  ab- 
scess, have  had  better  fortune  than  has  fallen  to  my  share,  as  they  have 
never  appeared  to  me  to  exert  any  material  influence  over  its  course. 

The  only  remedy  from  which  I  have  ever  found  benefit  arise  is  the  po- 
tassio-tartrate  of  antimony  in  large  doses,  aided  by  the  application  of  water 
at  nearly  scalding  heat  to  the  perineum,  and  sometimes  the  free  applica- 
tion of  the  nitrate  of  silver  to  the  surface. 

In  six  cases  out  of  eight  in  which  I  collected  the  histories,  and  had  an 
opportunity  of  tracing  them  to  their  close,  a  complete  though  slow  cure  of 
the  abscess  took  place  ;  the  gonorrhoea,  however,  proved  more  difficult  to 
subdue  than  in  most  other  cases.  In  the  seventh  the  patient,  just  as  the 
abscess  was  a  little  improved,  gave  up  the  medicine  in  disgust,  and  soon 
returned  with  a  larger  and  more  painful  swelling.  This  was  also  subdued 
by  the  use  pf  antimony  ;  but  though  he  attended  regularly,  the  urethra 
long  felt  hard  and  tight  at  the  seat  of  the  abscess,  and  a  gleety  discharge 
remained  which  proved  very  intractable.  On  passing  the  bougie  the  canal 
did  not  appear  much  narrowed,  but  it  was  somewhat  twisted  and  peculiarly 
hard  and  inelastic ;  there  was  also  considerable  dribbling  after  making 
water.  More  than  a  year  after  this  I  met  him,  when  he  informed  me  that 
he  had  had  no  return  of  the  gleet,  but  the  uneasy  feeling  of  hardness  was 
still  there. 

The  eighth  case  was  that  of  a  gentleman  in  whom  the  abscess  had  been 
checked,  eighteen  months  previously,  by  the  heroic  use  of  leeches,  poul- 
tices, etc.  ;  since  that  time  the  discharge  had  never  diminished,  and  was  now 
thick  and  yellow.  He  had  taken  large  quantities  of  medicine,  principally 
copaiba  and  cubebs,  but  without  any  result,  except  that  of  increasing  dis- 
gust for  "  all  physicking."  For  three  or  four  months  he  tried  blisters, 
aperients,  and  short  syringe  injections  with  unwearied  perseverance,  but 
with  no  effect.  I  wanted  to  cauterize  the  urethra  and  use  bougies,  but  he 
said  he  had  suffered  so  much  that  he  could  not  bear  the  idea  of  more  in- 
struments. At  last  he  permitted  me  to  introduce  a  gum-elastic  bougie ; 
on  reaching  the  seat  of  the  abscess,  the  urethra  was  found  excessively  ten- 
der and  irregular.  Three  years  subsequently  he  again  consulted  me  for 
two  confirmed  and  very  tight  strictures  of  the  urethra,  one  of  which  was 
only  an  inch  and  a  half  from  the  orifice.  He  had  for  some  time  always 
carried  a  small  bougie,  which  he  occasionally  passed  a  little  way  down. 
The  discharge  had  never  ceased ;  his  health  seemed  quite  broken  down, 
and  he  presented  a  melancholy  picture  of  a  constitution  never  very  sound, 
now  to  all  appearance  ruined  for  want  of  resolution  to  undergo  a  mild  op- 
eration. He  still  persisted  in  refusing  to  allow  bougies  to  be  used.  Sub- 
sequently I  attended  him  for  complete  retention  of  urine,  and  succeeded 
in  passing  a  No.  2  catheter  with  the  greatest  difficulty,  just  as  the  symp- 
15 


226  ON    GONORRHCEA. 

toms  had  become  too  serious  to  admit  of  further  delay,  and  after  I  had  re- 
solved, if  this  failed,  to  pierce  the  bladder  from  the  rectum.  Although  he 
knew  in  what  jeopardy  his  life  had  been  placed,  and  though  strangely 
enough  his  brother  died  about  this  time  from  stricture,  he  seemed  after 
his  recovery  to  grow  more  indifferent  than  ever. 

These  cases,  coupled  with  others  which  I  could  not  watch  so  completely, 
quite  impressed  me  with  the  conviction,  not  only  that  perineal  abscesses 
should  be  attacked  with  the  utmost  vigor,  but  also  that  the  treatment  ought 
to  be  continued  till  the  hardness  has  disappeared.  Subsequent  experience 
has  enabled  me  to  verify  this  opinion  ;  and  of  late  years  I  have  always,  so 
soon  as  the  antimony  had  checked  the  inflammation,  used  the  iodide  of 
potassium  in  combination  with  liquor  potassae  till  some  effect  was  produced. 
The  perineum  should  be  blistered  as  often  as  the  patient  will  allow  it,  and 
during  the  intervals  blue  ointment  combined  with  camphor  may  be  rubbed 
in  every  night.  The  bougie  is  also  to  be  passed  twice  a  week,  so  soon  as 
the  state  of  the  urethra  will  permit.  If  suppuration  cannot  be  averted,  the 
matter  should  be  let  out  by  a  small  puncture  with  an  insect-needle.  Mr. 
John  Marshall  has  used,1  with  great  success,  solution  of  morphia  in  oleate 
of  mercury  as  an  outward  application  in  threatening  abscess  of  the  peri- 
neum from  inflammation  of  one  of  Cowper's  glands,  as  also  in  epididymitis ; 
in  one  case  where  I  tried  it  the  result  was  decided  failure. 

12.  INFLAMMATION  OF  THE  PROSTATE.  Pathology,  Divisions. — Three  forms 
are  distinguished.  1.  Acute,  marked  by  acute,  often  violent,  burning  pain 
in  perineum,  aggravated  by  walking  or  even  moving,  perineum  sometimes 
becomes  sensitive  to  every  touch,  feeling  of  a  foreign  body  in  rectum, 
great  difficulty  in  evacuating  bowels  and  making  water,  which  may  rise  to 
tenesmus,  strangury,  and  passing  of  water  drop  by  drop,  catheter  sud- 
denly arrested  at  prostate.  Sometimes  hypogastric  tension,  great  anxiety, 
and  even  fever  of  synochal  type.  After  a  day  or  two  pulsating  pain  in 
region  of  prostate  ;  one  or  more  lobes  of  the  gland  may  be  swollen,  fluc- 
tuation usually  in  eight  to  twelve  days,  possibly  marked  by  rigors.  2. 
Subacute  or  chronic  (Congestion  of  the  Prostate).  Heavy  dull  feeling  in  the 
perineum,  with  stiffness  and  heat,  particularly  on  standing  or  moving,  pain 
and  smarting  in  upper  part  of  thighs,  frequent  desire  to  make  water, 
pain  after  voiding  it,  possibly,  though  by  no  means  frequently,  some  mixt- 
ure of  blood  in  the  last  drops  of  the  urine,  often  urine  turbid,  not  unfre- 
quently  hypersecretion  of  mucus  in  urine,  or  there  may  be  small  strips  of 
mucus  in  it  mixed  with  pus  from  the  prostate.  Gland  not  much  en- 
larged ;  painful  on  firm  pressure.  Affection  seen  chiefly  in  my  experience 
when  the  patient  has  taken  much  copaiba  and  hard  exercise.  3.  Mucous, 
known  also  as  catarrhal  or  canalicular.  Affects  principally  the  mucous 
membrane,  from  the  ramifications  of  which  in  the  gland  drops  of  muco-pus 

'Lancet,  vol.  i.,  p.  711.     1872. 


TREATMENT.  227 

have  been  seen  at  an  autopsy  exuding  on  pressure,  the  stroma  not  being 
inflamed  or  even  red ;  but  organ  almost  always  tender. 

Prognosis. — Favorable;  I  believe  recovery  to  be,  even  in  bad  cases, 
almost  entirely  a  question  of  attention  and  sound  treatment. 

Results. — The  end  of  the  first  form  may  be  that  the  gland  becomes 
filled  with  matter,  generally  burst  by  passing  the  catheter,  though  it  may 
open  externally.  Not  unfrequently,  according  to  Fournier,1  the  inter- 
minable suppuration  from  a  prostatic  cavity  carries  the  patient  off  after  a 
long  period  of  suffering  and  cachexia.  Mr.  Phillips  says a  this  form  may 
end  in  gangrene.  A  case  of  death  from  abscess  of  the  prostate,  following 
upon  this  variety  of  the  affection,  occurred  some  years  ago  at  St.  George's 
Hospital,  under  the  care  of  Dr.  Pitman.3  The  patient  was  a  man,  aged 
five-and-twenty,  and  had  only  been  suffering  a  fortnight  when  he  was 
admitted,  eight  days  after  which  he  died.  The  abscess  was  not  detected 
during  life.  The  autopsy  revealed  nothing  beyond  extensive  suppuration 
in  the  gland,  and  profuse  purulent  discharge  from  the  urethra.  Indeed, 
but  a  few  years  ago,  when  it  was  thought  that  the  running  in  gonorrhoea 
is  the  natural  cure  of  the  disease,  and  the  effort  of  nature  to  throw  off 
the  virus,  death  from  disease  of  the  prostate  was  not  at  all  uncommon.4 
The  subacute  kind  may,  if  neglected,  end  in  very  obstinate  induration. 
The  follicular  order  frequently  degenerates  into  an  obstinate  gleet,  and  I 
shall  have  to  say  a  few  words  about  this  in  the  next  chapter. 

Treatment. — In  my  opinion,  when  we  have  to  deal  with  an  acute  case, 
the  remedy  before  all  others  is  tartar  emetic  as  recommended  for  abscess 
of  the  perineum,  and,  if  the  patient  object  to  this,  small  doses  of  calomel 
or  hydrargyrum  c.  creta,  a  good  sedative  «every  night,  rest  in  bed,  and  very 
light  diet.  Leeches  are  often  useful,  this  being  perhaps  the  only  compli- 
cation of  gonorrhoea  in  which  they  are  called  for,  and  patients  often  speak 
gratefully  of  the  benefit  derived  from  the  employment  of  them ;  but  in 
point  of  potency  they  are  far  behind  the  antimony,  the  operation  of  which 
should  be  seconded  by  a  resolute  and  persevering  scalding  of  the  perineum, 
•with  the  exhibition  of  a  full  dose  of  some  gentle  aperient,  such  as  syrup  of 
senna,  or  castor-oil  in  hot  milk  in  the  morning.  As  to  enemata  and  sup- 
positories, they  have,  the  latter  especially,  always  given  more  pain  when  I 
have  seen  them  used  than  done  good,  and  I  quite  concur  with  Dr.  Erskine 
Mason  5  in  objecting  to  their  employment.  So  soon  as  the  more  acute 
symptoms  have  passed  off,  iodide  of  potassium  should  always  be  given. 
Brodie  relates 6  a  case,  where  the  patient  was  suffering  great  distress  from 
enlargement  of  the  gland,  which  was  two  or  three  times  its  ordinary  size. 
The  patien  tattributed  the  disease,  and  I  think  with  justice,  to  an  attack 

1  Nouveau  Dictionnaire,  tome,  v.,  p.  203.  2  Op.  citat.,  p.  303. 

3  Lancet,  vol.  i  ,  p.  408.    1860.  4  Howard  :  Op.  citat.,  vol.  i.,  p.  218. 

*  American  Journal  of  Syphilography,  etc.,  p.  289.     1870. 
6  Works,  vol.  ii.,  p.  503. 


228  ON    GONORRH(EA. 

of  gonorrhoea  ten  years  previously.  The  affection  had  existed  in  its  pres- 
ent form,  and  that  a  pretty  severe  one,  for  three  or  four  years.  Yet  two 
grains  of  iodide  of  potassium,  three  times  a  day,  in  about  seven  weeks  re- 
duced the  prostate  to  its  normal  dimensions,  and,  judging  from  my  experi- 
ence of  such  cases,  would,  if  taken  earlier,  have  saved  the  patient  all  these 
years  of  suffering.  So  soon  as  the  prostatic  affection  is  checked,  the  treat- 
ment of  the  gonorrhoea  may  be  resumed. 

Brodie  recommends  J  rest  in  bed  in  the  horizontal  position,  blood  to  be 
taken  from  the  loins  or  perineum  by  cupping,  from  the  latter  region,  how- 
ever, only  when  the  services  of  a  dexterous  cupper  can  be  secured  ;  when 
this  cannot  be  obtained,  then  leeches  to  be  applied  to  the  part.  Active 
aperients  are  to  be  exhibited,  followed  by  opiates  in  the  form  of  an  enema 
or  suppository.  After  the  bowels  have  been  freely  opened,  calomel,  in 
doses  sufficient  to  bring  on  the  mercurial  action,  is  often  useful,  and  if  there 
be  retention  of  urine,  a  small  gum  catheter  is  to  be  introduced,  and  the 
water  drawn  off  when  necessary.  But,  even  with  so  great  an  authority 
against  me  I  do  not  hesitate  to  say  that  the  tartar  emetic  is  more  effica- 
cious. In  bad  cases  Fournier  applies  twenty  to  thirty  leeches  two  or  three 
times  in  succession.  When  any  part  of  the  prostate  remains  tender  and 
swollen,  as  also  in  indolent  swelling  after  epididymitis,  Dr.  Schuster  finds 
the  Aix-la-Chapelle  warm  sulphur-baths  very  useful  At  the  same  time  I 
must  observe,  that  the  recorded  effects  do  not  seem  to  exceed  those  follow- 
ing the  plan  recommended,  which,  thoroughly  carried  out,  rarely,  I  believe, 
fails. 

For  the  second  and  third  forms  nitrate  of  potass  in  five  to  ten  grain 
doses  three  times  a  day  in  infusion  of  cascarilla  or  snake-root,  or  bromide 
of  potassium  fifteen  to  twenty  grains  every  four  or  five  hours,  with  the 
mercury  and  sedative  at  night,  can,  I  think  be  quite  relied  on.  This  treat- 
ment must  be  supplemented  by  hot  bathing,  blistering,  rest,  and  iodide  of 
potassium,  just  the  same  as  the  other. 

13.  INFLAMMATION  OF  THE  SEMINAL  VESICLES. — I  have  no  personal  experi- 
ence of  anything  like  active  inflammation  of  these  bodies  being  set  up  by 
gonorrhoea  ;  but  it  seems  pretty  certain  that  an  action  closely  resembling 
irritability  of  the  bladder  is  sometimes  thus  induced,  for  I  have  seen  vesic- 
ular gleet  developed  by  gonorrhoea  and  prove  rather  difficult  to  cure.  M. 
Velpeau  was  in  the  habit  of  pointing  out  the  rather  frequent  occurrence  of 
a  certain  degree  of  inflammation  in  these  bodies  from  gonorrhoea.  In  a 
few  rare  autopsies,  according  to  Fournier,  the  appearances  were — general 
tumefaction  with  hardness,  injection  of  the  mucous  membrane,  the  seminal 
fluid  sometimes  replaced  by  yellow  muco-pus,  in  which  the  microscope 
showed  pus-globules.  Godard  twice  saw  atrophy  of  these  organs.  Respect- 
ing the  treatment  of  the  inflammatory  form  I  can  say  nothing  worth  the 


"'  Works,  vol.  ii.,  p.  191. 


TREATMENT.  229 

reader's  attention  ;  that  of  the  latter  consists  of  tonics,  with  mild  aperients 
to  obviate  the  irritation  set  up  by  hard  stools,  blisters  to  the  perineum, 
and,  when  the  urethra  remains  irritable,  weak  injections  of  nitrate  of  silver 
with  the  long  syringe  described  at  page  172.  It  is  perhaps  scarcely  neces- 
sary to  caution  the  junior  practitioner  and  student  here  as  to  the  diagnosis, 
by  digital  examination,  of  an  inflamed  and  projecting  prostate,  only  about 
an  inch  from  the  entrance  of  the  gut,  and  with  no  very  marked  parting 
between  its  lobes ;  and  of  the  vesicles,  which  can  scarcely  be  reached  with 
the  finger  and  are  widely  separated. 

14.  GONORRHCEAL  PERITONITIS. — Although  those  authors  who  have  touched 
upon  the  subject  seem  undecided  whether  this  complication  and  phleg- 
monous  inflammation  of  the  cellular  tissue  outside  the  peritoneum  are  due 
to  extension  of  the  orchitic  inflammation  along  the  vas  deferens  to  the 
cavity,  or  that  of  gonorrhoea  from  inflamed  seminal  vesicles,  I  am  quite 
disposed  to  think  that,  as  regards  the  phlegmonous  inflammatiou  at  least, 
we  must,  supposing  either  can  be  looked  upon  as  a  profitable  factor,  lay 
the  burden  upon  the  vesicles.  Were  such  a  result  due  to  propagation 
along  the  vas  deferens,  we  should,  judging  from  the  frequency  with  which 
this  occurs,  see  abdominal  complications  more  often.  Besides,  it  is  at  least 
as  probable  that  a  suppurative  inflammation,  such  as  is  noticed  in  the  ves- 
icles, would  set  up  a  similar  form  of  action  within  the  abdomen,  as  that 
this  should  result  from  the  affection  of  the  deferent  canal,  which  I  believe 
never  ends  in  the  formation  of  pus.  For  such  reasons  I  have  decided  to 
take  these  complications  here.  Hunter,  however,  had  a  case  of  peritoneal 
inflammation,  arising  in  his  opinion  from  the  vas  deferens  being  affected 
by  gonorrhoea  "  in  its  course  through  the  belly  and  pelvis."  According  to 
Fournier  '  Eicord  has  several  times  seen  this  complication,  which,  judging 
from  the  context,  must  be  supposed  to  have  arisen  in  the  same  way.  Cases 
have  also  been  recorded  by  Messrs.  Gosselin  and  Godard.  In  the  first  case 
mentioned 2  by  the  former  of  these  two  authors,  the  inflammation  seemed 
clearly  to  extend  from  the  right  testicle  by  the  corresponding  vas  deferens 
and  seminal  vesicle,  the  latter  being  extremely  tender  on  pressure,  although 
the  orchitis  was  not  very  marked.  The  attack  was,  however,  very  slight, 
the  patient  being  much  better  the  next  day,  though  only  the  most  simple 
means  were  used  ;  the  disorder  being  apparently  supplanted  by  a  large 
swelling  of  the  cauda  and  lower  half  of  the  body  of  the  epididymis. 

So  far  back  as  1856  M.  Peter  published  a  case  of  gonorrhoea!  orchitis 
followed  by  inflammation  of  one  of  the  seminal  vesicles,  and  then  of  the 
peritoneum  and  pleura,  ending  fatally.  The  patient  was  a  delicate  lad, 
sixteen  years  old,  admitted  into  the  hospital  for  orchitis  of  the  left  side. 
Ten  days  after  entering  he  was  attacked  with  shiverings,  feeling  of  illness, 


1  Nouveau  Dictionnaire,  tome  v.,  p.  214. 
s  Gazette  des  Hopitaux,  p.  434.    1873. 


230  ON    GONORRHOEA. 

nausea,  vomiting,  which  became  bilious  and  abundant,  and  pains  in  the 
abdomen,  slight  at  first  and  then  growing  severe.  There  was  no  abdominal 
distention,  but  the  patient  rested  fixedly  on  his  back  ;  there  was  slight 
cough  with  dyspnoea ;  no  hiccough.  The  pulse  was  105  and  compressible  ; 
there  was  great  thirst,  accompanied  by  repeated  and  abundant  bilious 
vomiting.  The  orchitis  does  not  seem  to  have  been  very  severe,  and  the 
indurated  epididymis  was  not  very  painful  to  the  touch.  The  case  was 
diagnosed  as  peritonitis,  due  to  extension  of  the  gonorrhoeal  inflamma- 
tion through  the  medium  of  the  vas  deferens  and  seminal  vesicle,  and  was 
treated  with  leeches,  mercurial  inunctions,  cataplasms,  and  ice.  Delirium 
came  on,  the  left  side  of  the  chest  became  painful,  and  the  patient  died  in 
a  week  from  the  beginning  of  these  symptoms,  and  sixteen  days  after  ad- 
mission. M.  Peter  expresses  the  opinion  that,  in  this  case  there  was  in- 
flammation by  contiguity  as  well  as  by  continuity. 

At  the  autopsy  a  litre  of  purulent  fluid  was  found  in  the  pelvic  basin, 
the  intestines  were  covered  with  purulent  and  glutinous  serum  ;  there  was 
some  amount  of  false  membrane  on  the  ascending  colon  and  liver.  The 
urethra  was  red  at  its  anterior  part ;  the  veru  montanum  of  remarkable  pale- 
ness ;  both  the  ducts  and  stroma  of  the  prostate  were  inflamed.  In  the 
right  seminal  vesicle  was  a  small  quantity  of  spermatic  fluid  which  con- 
tained epithelial  cells,  molecular  granules,  and  a  few  dead  spermatozoa.  ID 
the  left  vesicle  was  found  a  small  quantity  of  purulent  liquid,  in  which  the 
microscope  showed  existence  of  pus-cells,  mixed  with  epithelial  cells,  but 
no  spermatozoa.  This  vesicle  was  larger  than  the  other,  owing  to  the 
surrounding  cellular  tissue  being  much  injected  and  thickened  ;  the  peri- 
toneum underlying  it  was  more  vascular  than  any  other  part  even  at  the 
seats  of  inflammation.  At  the  point  where  it  turns  round  the  left  seminal 
vesicle  the  vas  deferens  was  much  injected,  as  was  also  the  surrounding 
cellular  tissue.  There,  as  in  its  pelvic  portion,  this  duct  was  swollen,  hard, 
and  firmly  adherent  to  the  peritoneum  which  covered  it.  The  overlying 
cellular  tissue  was  hardened  ;  the  mucous  membrane  of  the  canal  pale.  The 
left  epididymis  larger  than  the  right. 

Prognosis. — Serious,  three  patients  out  of  five  attacked  having  died. 
Founder  admits  the  possibility  of  this  grave  result.  Of  the  treatment  I 
cannot  speak,  having  seen  no  cases  myself,  and  having  found  no  directions 
in  any  work  or  paper. 

15.  SUB-PERITONEAL  INFLAMMATION.— Some  years  later1  M.  Faucon  ad- 
dressed a  note  to  the  Societe  de  Chirurgie  on  the  subject  of  this  complica- 
tion which  he  connects  with  the  peritonitis  of  gonorrhoea,  first  mentioned 
by  Hunter  as  due  to  the  gonorrhceal  inflammation  having  extended  by  the 
vas  deferens,  but  no  further  investigation  of  the  subject  took  place  till  the 
publication  of  his  own  excellent  memoir2  on  the  subject. 

1  October  22,  1873.         *  Archives  Generales  de  Medecine,  tome  ii,  p.  385.    1877. 


TREATMENT.  231 

In  a  case  of  this  inflammation,  following  upon  gonorrhoea!  cystitis  and 
orchitis  of  the  right  side,  described  '  by  him,  he  says  there  was  no  swelling 
over  the  tract  of  the  cord,  but  the  patient  pointed  to  the  sub-inguinal  and 
inguinal  parts  of  this  line  as  the  chief  focus  of  the  pains  which  he  felt  in 
the  whole  of  the  hypogastric  region,  and  which  seemed  to  radiate,  growing 
weaker  from  the  inguinal  region  toward  the  surrounding  parts.  The  pain 
was  increased  by  pressure.  Fever,  which  seems,  though  not  expressly 
stated,  to  have  accompanied  the  orchitis,  reappeared,  the  patient  felt  very 
unwell,  and  during  the  following  twelve  days  considerable  tumefaction  of 
the  sub-peritoneal  cellular  tissue  took  place.  At  first  there  was  a  sort  of 
puffiness,  appreciable  only  to  the  touch,  at  the  lower  part  of  the  internal 
iliac  fossa.  This  puffiness  extended  rapidly  to  the  inner  inguinal  ring.  It 
was  then  found  that  the  wall  of  the  abdomen  was  not  invaded,  but  at  the 
end  of  a  few  days  this  in  its  turn  was  attacked,  and  became  the  seat  of  a 
dense  induration  like  wood  (ligneuse),  quite  separate  from  the  skin,  ex- 
tending to  four  fingers'  breadth  above  the  fold  of  the  groin.  At  one  time 
the  swelling  of  the  vas  deferens  was  fused  with  the  induration  of  the  ab- 
dominal wall.  The  pain,  which  had  at  first  been  dull  without  throbbing, 
was  speedily  accompanied  by  nocturnal  exacerbations  which  entirely  (!) 
deprived  the  patient  of  sleep.  The  pain  stretched  along  the  iliac  crest  and 
in  the  direction  of  the  navel,  but  never  toward  the  thigh.  The  pain  was 
increased  by  coughing,  laughing,  and  speaking,  and  pressure  even  elicited 
a  cry  of  pain.  Movements  of  flexion  and  extension,  though  restricted, 
were  practicable  so  long  as  the  patient  remained  in  bed,  but  became  much 
more  painful  and  difficult  when  he  stood  up  for  a  few  minutes.  The 
inguinal  and  scrota!  parts  of  the  cord  remained  normal.  The  general 
health  was  bad,  there  being  continual  fever,  with  a  pulse  of  100  to  105, 
accompani  d  by  low  delirium  at  night  even  when  the  patient  was  wide 
awake.  The  tongue  was  thickly  coated,  and  there  was  complete  anorexia 
with  thirst  and  obstinate  constipation.  The  affection  evidently  lasted  in  a 
very  severe  form  from  August  3d  to  October  20th,  and  at  one  time  as- 
sumed such  a  grave  aspect  that  M.  Faucon  cut  down  more  than  an  inch  (4 
centimetres)  deep  in  search  of  pus,  but  found  none. 

M.  Faucon  considers  that  both  gonorrhoea!  peritonitis  and  sub-perito- 
neal inflammation  appear  in  the  third  to  the  fourth  week  of  the  discharge, 
a  statement  of  great  moment  as  respects  the  diagnosis,  particularly  when 
we  are  told "  that  in  Velpeau's  case  the  peritonitis  remained  undetected  for 
four  days. 

Prognosis. — Serious  here  also,  for  though  I  do  not  anywhere  find  death 
mentioned  as  the  result,  it  is  clear  that  the  course  and  symptoms  were  of 
a  nature  to  awaken  great  anxiety. 

Treatment. — M.  Faucon   recommends  energetic  use  of  antiphlogistic 


1  Archives  Generates  de  Modecine,  tome  ii.,  p.  394.     1877.  2Ibid.,  p.  558. 


232  ON    GONORRHCEA. 

measures,  prolonged  employment  of  ice,  and  preventive  division  of  any 
constriction  in  the  affected  parts.  Along  with  this  complication  may,  I 
think,  very  properly  be  placed  that  which  follows. 

16.  GONORRHCEAI,  PERiNEPHRiTic  ABSCESS. — A  case  of  this,  the  predispos- 
ing  cause  being  evidently  gonorrhoea,  is  mentioned  by  M.  Laforgue.1  The 
patient,  a  young  man,  age  not  given,  had  used  some  quack  injection  to  cure 
a  gonorrhoea,  which  had  the  effect  of  arresting  the  discharge  ;  then,  having 
indulged  in  a  debauch,  he  was  seized  with  retention  of  urine  which  re- 
quired the  immediate  use  of  the  catheter  and  antiphlogistic  treatment. 
The  passing  of  the  instrument  was  painful,  and  revealed  a  tender  and  swol- 
len state  of  the  prostate,  which  had  been  the  cause  of  the  stoppage.  The 
bladder  became  inflamed,  and  notwithstanding  the  most  energetic  emplo}'- 
ment  of  hip-baths,  belladonna  inunctions,  and  so  on,  very  little  relief  was 
obtained.  There  was  great  f  everishness  with  exacerbations  at  night.  The 
pain  and  difficulty  in  making  water  slowly  gave  way,  but  the  straining  of 
the  bladder  caused  persistent  suffering,  and  the  urine  was  fetid  and 
charged  with  membranous  debris.  The  patient  felt  ill,  lost  his  appetite, 
and  suffered  from  constant  pain  in  the  hypogastric  region.  After  drag- 
ging on  in  this  way  for  three  weeks  he  was  suddenly  attacked  with  shiver- 
ing and  intense  abdominal  pain,  accompanied  by  tumefaction  of  the  right 
lumbar  region,  which  also  extended  to  the  right  iliac  region.  The  lumbar 
swelling  was  opened  and  gave  issue  to  a  large  quantity  of  pus.  The  reason 
of  the  collection  forming  in  this  part  is,  according  to  M.  Laforgue,  that 
such  abscesses  have  their  seat  behind  the  kidney  which  separates  them  from 
the  peritoneum. 

The  following  case  by  Dr.  Alexander 2  was  evidently  enough  of  much 
the  same  nature.  The  patient  had  been  treated  for  gonorrhoea  with  aperi- 
ent salines  and  alkalies,  under  the  influence  of  which,  apparently,  the  dis- 
charge ceased.  Soon  after  he  began  to  feel  unwell  and  lost  his  appetite  ; 
pain  came  on  in  the  left  lumbar  region.  The  skin  became  hot,  thermome- 
ter in  mouth  105°.  A  diaphoretic  with  aconite  reduced  the  temperature, 
but  the  tongue  was  furred  and  bilious  vomiting  set  in,  accompanied  by 
"  horrid "  pain  in  left  loin,  which  hot  fomentations  failed  to  relieve ;  in- 
deed he  continued  to  get  worse,  and  at  the  end  of  eleven  days  complained 
that  the  pain  was  extending  round  the  back  to  the  right  side.  On  examin- 
ing, a  small  immovable  tumor,  with  a  doughy  feel,  was  found  two  inches 
to  the  left  and  on  a  level  with  the  umbilicus.  The  patient  was  now  moan- 
ing, restless,  and  bathed  in  perspiration,  the  tongue  was  hard  and  brown. 
Hypodermic  injections  were  ordered  to  induce  quiet,  and  castor-oil  and 
croton-oil  to  clear  the  bowels  well  out.  On  the  nineteenth  day  there  was  a 
distinct  feeling  of  fluctuation  in  the  tumor  ;  the  next  day  a  needle  was  in- 

1  Revue  medicale  de  Toulouse.     Quoted  in  Gazette  des  Hopitaux,  p.   316.  1877. 
Also  in  Archives  Generates  de  Medicine,  tome  ii.,  p.  547.     1877. 
''Lancet,  vol.  i.,  p.  538.    1881. 


TREATMENT.  233 

serted  into  the  most  prominent  part  of  it,  in  front  and  two  inches  to  the 
left  of  the  umbilicus.  Seven  ounces  of  healthy  pus  were  drawn  off,  and 
two  days  later  seven  ounces  more  ;  another  day  twenty  ounces  were 
taken,  and  again  on  another  twenty-two,  the  patient  finally  recovering. 
The  treatment  after  the  aspiration  was  commenced  is  not  stated. 

17.  GONORRH<EAL  (?)  PvELiTis  AND  NEPHRITIS. — Two  fatal  cases  of  this 
affection  consequent  on  gonorrhoea  were  reported  to  the  Clinical  Society.1 
In  consequence  of  both  patients  being  admitted  into  the  hospital  in  an  un- 
conscious state,  no  history  was  obtained  of  either  till  after  death,  and  the 
real  nature  of  the  disease  was  only  revealed  by  autopsy  ;  but  Dr.  Murchi- 
son,  who  communicated  the  cases,  entertained  little  doubt  as  to  the  exact 
state  in  each  of  them. 

The  first  was  that  of  a  man,  twenty-eight  years  of  age,  brought  to  the 
hospital  in  a  state  of  profound  coma,  with  low  muttering  delirium  and  dry, 
brown  tongue.  He  had  several  attacks  of  general  convulsions  after  enter- 
ing, and  died  in  three  hours  from  his  admission.  He  had  suffered  from 
gonorrhoea  for  some  time,  but  the  cerebral  Symptoms  only  came  on  thirty 
hours  before  he  was  made  in-patient.  After  death  the  entire  length  of  the 
urinary  passage,  from  the  anterior  end  of  the  urethra  to  the  pelves  of  the 
kidneys,  was  found  to  be  in  a  state  of  intense  inflammation,  the  mucous 
membrane  being  brightly  injected  and  the  surface  bathed  with  pus.  Both 
ureters  were  full  of  thick  yellow  pus.  Both  kidneys  were  in  the  first  stage 
of  acute  nephritis,  and  their  pelves  were  full  of  pus.  The  lungs  were  much 
congested  in  their  dependent  parts,  and  in  the  lower  lobes  were  a  few  small 
patches  of  incipient  lobular  pneumonia. 

The  other  case  was  that  of  a  woman  twenty-five  years  old.  She  was 
unconscious  at  the  tune  of  admission,  but  constantly  moaning.  Her  coun- 
tenance was  dusky  and  her  breathing  labored  ;  the  pupils  were  equal,  but 
there  was  slight  internal  strabismus  of  both  eyes.  There  were  signs  of 
hypostatic  congestion  of  the  lungs.  She  gradually  became  comatose,  and 
after  two  convulsive  fits  died  on  the  second  day  from  admission,  the  cere- 
bral symptoms  having  begun  the  day  before  she  entered.  Autopsy  showed 
membranes  and  substance  of  brain  intensely  hyperaemic ;  no  exudation  of 
lymph,  no  sign  of  tubercle  either  in  cranium  or  lungs.  Lungs  congested 
in  dependent  parts,  otherwise  healthy.  Both  kidneys  in  early  stage  of  acute 
nephritis  ;  large,  smooth,  and  almost  black  from  intense  congestion.  Ure- 
ters and  pelves  of  kidneys  full  of  thick  yellow  pus  ;  the  bladder  also  con- 
tained pus.  The  lining  membrane  of  the  vagina,  urethra,  bladder,  ureters, 
and  pelves  of  kidneys  intensely  red. 

Dr.  Greenhow  saw  2  a  case  which  seems  to  have  been  of  a  similar  nature, 
the  man  having  died  in  a  state  of  coma  which  lasted  thirty-six  hours.  He 
was  at  first  thought  to  have  been  poisoned,  but  the  case  was  diagnosed 

1  Transactions,  vol.  ix. ,  p.  25. 

*  British  Medical  Journal,  vol.  iL,  p.  718.  1875. 


234  ON    GONOKRIKEA. 

as  cerebral  metastasis  from  gonorrhoea  checked  by  treatment,  though  it 
seems  to  me  that  the  gonorrhoea  was  actually  exiting  at  the  time  of  ad- 
mission. 

18.  GONORRHCEAL  (?)<;^SUBITIS. — The  existence  of  a  form  of  pleurisy,  de- 
rived from  gonorrhoea  in  the  same  sense  as  rheumatism  arises  from  it,  seems 
to  me  doubtful  in  the  highest  degree.     Tixier  mentions '  a  case  which  he 
says  was  clearly  gonorrhoeal,    "  bien  nettement  blennorrhagique,"  but  I 
question  whether  it  will  be  accepted  as  such.     The  dates  are  not  given  with 
accuracy,  but  the  patient  seems  to  have  had  a  slight  attack  of  pleurisy  of 
the  right  side,  which  came  on  when  he  had  been  suffering  for  a  long  time 
from  gonorrhoea,  not  a  very  unusual  incident  I  should  say.     He  left  the 
hospital  with  the  gonorrhoea  uncured,  and  had  a  relapse  of  the  pleurisy,  at 
which  point  the  history  and  evidence  alike  end.     Gonorrhoeal  pericarditis, 
endocarditis,  and  some  allied  affections  being  more  intimately  connected 
than  the  foregoing  with  rheumatism,  indeed  almost  to  be  viewed  as  results 
and  complications  of  the  latter,  will  be  considered  after  it 

19.  GONORKHCEAL   RHEUMATISM. — History. — M.  Voelker,  in  a   most  able 
and  exhaustive  treatise  2  on  this  subject,  tells  us  that  this  form  of  rheu- 
matism was  described  by  Martiniere  in  1644,  who,  however,  only  says  we 
must  not  suppress  gonorrhoea  too  quickly  for  fear  of  bringing  on  pains 
similar  to  those  of  rheumatism.     He  then  traces  it  through  Blankard,  1688, 
Ucay,  1702,  Astruc,  1743,  and  Col  de  Villars,  1759,  the  evidence  of  all  four, 
however,  being  very  doubtful.     Some  time  previously  M.  Eicord  had  re- 
marked that  the  affection  was  pointed  out  by  our  countryman,  William 
Musgrave,  in  1723.     I  have  not  seen  any  work  by  Musgrave  of  this  date, 
but  the  account  given  in  an  earlier  one  s  is  not  at  all  satisfactory.     He 
says  *  "  the  baleful  practice  of  empirics  exasperates  the  tendency  to  arthri- 
tis, for  these  busybodies,  in  treating  gonorrhoea,  attend  too  much  to  the 
suppression  of  the  purulent  discharge  only,  neglecting  or  carrying  out 
very  remissly  what  ought  to  be  chiefly  and  sedulously  enforced,  namely 
purging.     The  enemy,  being  thus  detained  within  the  frame,  enters  the 
blood  and  parts  in  greater  force,  and  with  unimpaired  virulence,  first 
bearing  the  principles  of  the  venereal  disease  (Patursa),  and  then  in  time 
generating  a  species  of  arthritis."    I  do  not  see  the  slightest  proof  in  this 
or  in  anything  which  follows  that  Musgrave  discriminated  at  all  between 
gonorrhoeal  rheumatism  and  the  rheumatoid  pains  of  syphilis  ;  he  must  at 
least  have  seen  the  latter,  and  if  he  did  see  the  former,  must  have  observed 
very  badly  to  confound  together,  as  he  evidently  does,  two  diseases  so 
distinct.     Voelker  then  tells  us  that  the  affection  was  further  described  by 
Selle  and  Swediaur,  1781,  by  Colle,  no  date  given,  and  by  Yvan  in  1806, 
from  which  time  onward  its  history  need  not  be  traced,  the  disease  being 

1  Considerations  sur  les  Accidents  a  Forme  rhumatismale,  p.  59.  1866. 

5  De  1'Arthrite  Blennorrhagique.    1868. 

1  De  Arthritide  Symptomatica.    1703.  4  P.  132. 


TKEATMENT.  235 

noticed  with  steadily  increasing  frequency.  Brandes,  of  Copenhagen,  says ' 
it  was  mentioned  by  Monteggia  in  a  work  2  which  I  have  not  been  able  to 
find. 

To  revert  however  for  one  moment.  The  date  of  Swediaur's  work,  in 
which  he  speaks  of  the  affection,  is  given  by  some  authors  as  1781 ;  that 
of  1788,  however,  which  was  the  only  one  in  the  Library  of  the  College  of 
Surgeons,  when  in  a  previous  edition  I  gave  a  very  brief  account  of  the 
complaint,  does  not  contain  a  word  about  the  matter.  Indeed,  though 
Swediaur  devotes  several  pages  of  it  to  a  general  abuse  of  Hunter,  he  never 
seems  to  have  noticed  that  the  latter  writer  records  a  case  of  the  affection. 
In  the  edition  of  1819,  afterward  added  to  the  Library,  there  is  a  brief 
notice  3  of  it.  t  He  calls  the  disorder  gonorrhoeal  rheumatism,  and  describes 
it  as  attacking  the  knee,  and  yielding  to  mild  diluents,  and  a  liquid  oint- 
ment made  with  " gum  resin  ammoniac"  and  vinegar  of  squills.  He  does 
not  seem  to  have  had  any  idea  of  its  distinctive  characters.  In  his  lectures, 
1806-07,  Sir  Astley  Cooper  describes  the  disease,  in  so  far  that  he  narrates 4 
the  case  of  a  patient,  who  told  him  that  gonorrhoea  was  always  followed 
in  him  (the  patient)  by  rheumatism  ;  and  he  adds  that  this  proved  to  be 
so,  for  it  ensued,  in  a  very  obstinate  shape,  in  the  very  case  for  which 
Cooper  was  consulted.  He,  too,  does  not  seem  to  be  aware  that  the  disease 
is  a  separate  and  very  unmanageable  variety. 

All  the  esential  features  in  the  discoveries  of  Swediaur  and  Cooper 
were  made  known  by  Hunter  as  far  back  as  1786.  "I  know,"  he  says,5 
"one  gentleman  who  never  had  gonorrhoea  but  that  he  was  immediately 
seized  with  rheumatic  pains ;"  and  Whately,6  writing  in  1801,  reports  a 
case  where  a  patient  with  gonorrhoea  was  seized  with  rheumatism  of  one 
wi'ist,  then  in  the  other  wrist,  and  afterward  both  knees  in  succession  ; 
after  another  attack  of  gonorrhoea  the  patient  again  had  rheumatism,  first 
in  one  knee  and  then  in  the  other,  and  then  again  in  the  ankles  and  wrists. 
I  believe  every  person  who  reads  Whately's  work  will  feel  sure  that  he 
considered  these  affections  of  the  joints  to  be  gonorrhoeal.  But  Brodie 
was  the  first  who  in  England  recognized  the  true  nature  of  the  disease  and 
made  it  known.  I  do  not  see,  in  any  writer  before  his  time,  the  least 
proof  that  its  distinguishing  features  and  obstinate  character  had  been  ap- 
preciated ;  and  I  think  any  one  who  will  compare  Swediaur's  fragmentary 
description,  and  his  ridiculous  statement  about  the  affection  yielding  to 
diluents  and  ammoniac,  with  Brodie's  luminous  account  and  his  clear  recog- 
nition of  its  resistance  to  treatment,  will  come  to  much  the  same  opinion 
as  myself. 

Pathology. — Of  all  the  complications  of  gonorrhoea  this  is  one  of  the 


1  Archives  Generates  de  Medecine,  tome  ii.,  p.  265.  1854. 
5  Eemarques  pratiques  sur  les  Maladies  veneriennes.  1798. 
3  Vol.  i.,  p.  252.  4  Lancet,  vol.  iii.,  p.  301. 

6 Op.  citat.,  p.  51.  60p.  citat.,  p.  75. 


236  ON    GONOERHffiA. 

most  formidable  and  the  least  amenable  to  treatment.  I  therefore  propose 
to  consider  it  somewhat  in  detail,  especially  as  very  contradictory  opinions 
prevail  respecting  its  etiology ;  the  first  question  that  meets  us  on  the 
way  being  that  of  whether  there  really  is  a  true  gonorrhoeal  rheumatism, 
distinct  from  the  ordinary  form,  and  due  to  gonorrhoea  only. 

Dr.  Elliotson '  held  that  this  affection  is  not  due  to  gonorrhoea  at  all, 
because  in  some  cases  there  is  no  history  of  infection  ;  he  seems  to  have 
believed  that  the  rheumatism  and  discharge  might  come  on  together,  with- 
out the  patient  having  had  connection,  the  running  being  in  fact  merely  a 
manifestation  of  rheumatism,  an  idea  which  I  have  seen  twice  put  forward 
since  his  time.  The  chief  reason  for  the  belief  seems  to  be,  that  occasion- 
ally the  two  affections  show  themselves  when  the  urethra  of  a  patient,  la- 
boring under  stricture,  has  been  irritated,  and  when  there  is  no  proof  of 
gonorrhceal  infection.  But  the  evidence  against  this  opinion  is  strong. 
In  all  the  cases  that  I  have  seen  the  rheumatism  complicated  undoubted 
gonorrhoea.  For  many  years  I  have  never  been  without  cases  of  stricture 
under  my  care,  yet  up  to  the  present  hour  I  have  not  seen  gonorrhoeal 
rheumatism  from  this  lesion.  Stricture  itself  means,  often  enough,  un- 
cured  gonorrhoea  or  gleet.  Dr.  EUiotson's  treatment  was  not  calculated  to 
restore  the  urethra  to  a  healthy  state,  and  therefore  we  can  easily  under- 
stand that  an  irritant,  which  will  often,  under  such  circumstances,  renew 
the  purulent  secretion,  should  also  rouse  again  into  activity  the  slumber- 
ing disposition  to  rheumatism.  I  cannot  help  suspecting  that  this  is  the 
explanation  of  catheterism  setting  up  the  mischief.  Out  of  all  the  cases 
mentioned  by  Dr.  Elliotson,  and  those  writers  who  have  taken  his  side  of 
the  question,  there  is  not  one  where  we  can  feel  assured  that  the  urethra 
was  in  a  healthy  condition,  and  that  the  patient  had  not  been,  either  pre- 
viously or  recently,  exposed  to  infection,  and  no  other  evidence  is  to  be  re- 
lied on. 

Several  writers  have  espoused  similar  views ;  among  others  Mr.  Thomas 
Nunn,3  who  questions  the  fact  that  an  obstinate  and  peculiar  form  of 
rheumatism,  differing,  both  in  its  features  and  in  its  resistance  to  treat- 
ment, from  the  ordinary  complaint,  is  set  up  by  gonorrhoea  in  the  urethra. 
His  own  arguments  damage  the  conclusion  he  aims  at.  His  contention 
seems  to  be,  that  constitution  may  have  a  good  deal  to  do  with  the  mat- 
ter, because  some  persons  have  a  tendency  to  this  complaint,  a  fact  which 
no  one  ever  sought  to  controvert  if  the  foregoing  gonorrhoea  were  only 
admitted  ;  that  gout  may  give  rise  to  urethritis,  and  that  obstinate  strict- 
ure may  be  complicated  by  a  syphilitic  taint.  Granting  all  this,  I  cannot 
see  how  it  is  to  be  looked  upon  as  proof  that  gonorrhceal  rheumatism  does 
not  exist. 

I  would  meet  in  the  same  way  the  arguments  of  Brodie,3  and  Dr.  An* 

1  Medical  Times  and  Gazette,  vol.  L,  p.  642.     1860. 

*  Lancet,  vol.  ii.,  p.  909.     1871.  3  Works,  vol.  ii.,  p.  145. 


TREATMENT.  237 

gelo  Scarenzio. '  In  not  one  of  the  cases  described  by  the  former  is  there 
anything  to  show  that  the  disease  broke  out  in  a  person  who  had  never 
had  gonorrhoea  ;  in  most  of  them  there  is  proof  enough  that  this  had 
been  the  case  at  the  beginning  of  the  story,  and  that  an  uncured  state  of 
it  might  have  been  at  the  bottom  of  the  relapse.  TJrethritis  is  not  a  com- 
mon result  of  rheumatism  in  a  person  who  has  never  had  gonorrhoea,  yet 
this  is  substantially  what  Brodie  would  maintain.  In  one  of  Scarenzio's 
cases,  directly  he  stopped  the  urethral  discharge  with  the  nitrate  of  silver 
the  rheumatism  began  to  abate.  The  urethritis  returned,  and  with  it 
came  back  the  rheumatism  in  a  worse  form  than  ever ;  he  again  cauterized 
the  urethra  with  the  same  good  effect,  and  a  decline  in  the  rheumatism  at 
once  showed  itself.  It  is  so  purely  and  intensely  gonorrhoea!,  that  Four- 
nier  declares  he  has  had  under  him  patients  who  suffered  from  it  every 
time  they  had  gonorrhoea,  and  who  yet  contracted  simple  urethritis 
without  any  such  result ;  rather  strong  evidence  of  the  specific  nature  of 
gonorrhoea  itself.  It  has  been  seen  in  persons  who  had  previously  had 
ordinary  rheumatism,  three  out  of  twenty-nine  patients  treated  by  Dr. 
Pye-Smith  2  had  previously  suffered  from  rheumatic  fever  ;  this  I  never  ob- 
served. Twice  I  have  treated  gonorrhoea  in  persons  intensely  rheumatic. 
The  first  patient  had,  when  I  saw  him,  suffered  from  the  discharge  up- 
ward of  six  years.  He  never  had,  all  this  time,  a  sign  of  gonorrhoea! 
rheumatism.  Two  or  three  times  before,  and  once  while  under  my  care, 
he  was  attacked  by  common  lumbago.  It  came  and  went  as  this  affection 
usually  does,  yielding  on  one  occasion  to  simple  ironing.  The  urethral 
discharge  was  not  in  the  least  influenced  by  any  of  these  attacks.  The 
gleet  was  cured  and  never  returned,  but  the  lumbago  came  more  and  more 
frequently,  till  he  became  a  perfect  martyr  to  it -and  rheumatism  in  other 
places.  The  other  patient  had  been  severely  tormented  with  rheumatism 
for  quite  eighteen  months,  and  was  only  a  little  better  when  he  contracted 
the  discharge.  Though  he  had  orchitis  and  irritable  bladder,  no  exacer- 
bation of  the  rheumatism  ensued,  nor  did  any  other  form  of  this  complaint 
appear.  The  complaint  has  been  known  to  attack  the  same  patient  five 
successive  times  with  as  many  gonorrhoeas,  no  rheumatism  showing  itself 
while  he  remained  free  from  infection  ;  and  Fournier  pertinently  asks 
whether  any  other  affection  can  be  found  which  coincides  so  frequently 
with  gonorrhoea — a  question  which  some  pathologists  might  feel  a  good 
deal  of  difficulty  in  answering.  In  the  same  way  I  would  deal  with  the 
question  of  its  being  in  any  way  whatever  connected  with  gout,  a  hypothe- 
sis I  feel  compelled  to  reject  entirely. 

This  much  for  the  dependence  of  gonorrhoea!  rheumatism  on  a  special 
disease  of  the  urethra ;  to  the  best  of  my  judgment  it  differs  also  in  its  course 

1  Giornale  italiano,  vol.  ii. ,  p.  129.     1874. 

s  Guy's  Hospital  Reports.     Third  Series,  vol.  xix. ,  p.  344. 


238  ON    GONORRHCEA. 

and  symptoms  from  the  non-specific  form.  The  gonorrhoea!  variety  appears 
in  its  most  acute  and  formidable  shape,  without  any  of  those  symptoms  of 
general  disturbance  which  so  often  accompany  common  rheumatism.  The 
rheumatic  fever,  which  requires  a  six  weeks'  course  of  mint-water  to  cure, 
is  unknown  here.  In  all  the  cases  I  have  seen,  it  was  not  the  pyrexia  but 
the  pain  that  laid  the  patient  up.  Fournier  noticed '  fever,  but  slight  and 
of  brief  duration,  the  pulse  being  never  more  than  90  to  100.  M.  Quin- 
quaud,  too,  says  that  when  only  one  joint  is  attacked  there  may  be  a  little 
feverishness  and  the  temperature  may  rise  to  102^°  (39°  C.). 

The  great  prostration,  also,  which  we  see  in  the  rheumatism  of  every  day 
life,  the  gastric  derangements,  acid  sweats,  and  great  deposits  of  lithates 
are  absent.  In  my  experience  it  has  never  assailed  the  joints  generally  as 
in  rheumatic  fever,  and  this  is  the  experience  of  some  very  good  observers. 
It  affects  tendinous  sheaths  as  at  the  wrist  or  foot,  and  tendinous  bursae, 
more  frequently.  There  is  frequently  considerable  effusion  into  the  part, 
simulating  true  hydrarthrosis,  while  the  erysipelatous  redness  which  accom- 
panies ordinary  rheumatism  is  rarely  seen  in  this  form.2  The  effusion  of 
serum  into  the  joint,  when  it  does  take  place  (hydrarthrosis),  is  abnormally 
sudden  and  extensive,  and  peri-articular  effusion  into  the  cellular  tissue 
equally  so  ;  the  extremities  of  the  bones  have  been  found  much  more  en- 
larged, and  swelling  of  a  limb  has  been  noticed  to  a  greater  extent  than  is 
ever  observed  with  simple  rheumatism.  The  tissue  of  the  cartilages  is  at- 
tacked rather  than  the  synovial  membrane,  as  is  shown,  according  to  Mr. 
Davies-Colley,3  by  the  great  oedema  of  the  soft  parts  round  the  joint.  Its 
attack  is  more  sudden  and  concentrated,  its  decline  slower  and  less  sudden, 
while  both  seem  quite  independent  of  the  weather,  though  Voelker  adduces 
some  cases  to  show  that  a  chill  may  develop  it ;  and  the  same  effect  has  been 
noticed  from  a  wrench,  violent  effort,  etc.  The  same  author  contends  that 
climate  is  an  important  element  in  the  genesis  of  this  disease,  it  being  so 
rare  in  Italy  that,  at  Padua,  Vanzetti  and  Pinali  never  saw  a  case.  Tem- 
perament goes,  I  believe,  for  nothing  ;  but  Voelker  says  that,  out  of  fifteen 
cases  which  he  saw,  thirteen  occurred  in  persons  of  lymphatic  diathesis,  a 
statement  not  yet  corroborated,  I  believe,  by  the  experience  of  a  single  ob- 
server. He  also  states 4  that  of  these  fifteen  cases  twelve  happened  in  Jan- 
uary, March,  November,  and  December.  I  never  saw  it  attack  the  heart, 
and  all  the  industry  of  M  Morel B  only  enabled  him  to  collect  three  cases 
of  pericarditis  and  ten  of  endocarditis  following  this  form  of  rheumatism. 
When  we  recollect  then  how  common  this  is,  and  that  the  proportion  of 
heart  affection  to  rheumatic  fever  is  at  least  fifty  per  cent.,6  the  conclusion 

1  Gazette  Hebdomadaire,  p.  129.     1866. 

s  Gazette  des  Hopitaux,  p.  1185.     1877. 

8  Guy's  Hospital  Reports.     Third  Series,  vol.  xxvL,  p.  190.         4  Op.  citat. ,  p.  32. 

6  These  pour  le  Doctorat  en  Medeciue.    1878. 

6  Medical  Times  and  Gazette,  vol.  i.,  p.  32.     1883. 


TREATMENT.  239 

is  forced  upon  us  that  in  this  respect  also  there  is  an  essential,  irreconcilable 
difference  between  the  two  affections.  Ordinary  rheumatism,  when  it  does 
fasten  on  the  frame  with  such  severity  as  to  last  for  years,  is  almost  always 
more  general  and  formidable  at  the  outset  than  the  specific  kind.  It  is  not 
a  common  thing  for  the  first  attack  of  it,  in  a  purely  local  shape,  to  lay 
strong  men  up  for  three  or  four  months,  as  we  see  in  the  gonorrhceal  variety, 
and  never  to  return  till  the  patient  is  again  attacked  by  gonorrhoea. 

This  part  of  the  subject  has  been  argued  with  great  ability,  at  the 
Hospitals'  Society  in  Paris,  by  MM.  Lorain,  Fereol,  Hervieux,  Peter,  and 
Fournier,  in  a  debate  which  continued  upward  of  two  months,  and  which 
is  fully  repeated  in  the  Gazette  Hebdomadaire  for  1866  and  1867,  and  in 
the  Union  M'edicale  for  a  corresponding  date.  The  first-named  speaker 
maintained  '  that  gonorrhceal  rheumatism  may  arise  from  other  morbid 
conditions  than  urethritis,  but  his  arguments  were  previously  met  by  M. 
Fournier,  with  counter-arguments  of  superior  force,  in  a  memoir  commu- 
nicated to  the  society,2  and  later  on,  in  a  series  of  papers  published  in  the 
Annales  de  Dermatologie  for  1869. 

M.  Fournier  says  that  the  essential  cause  of  the  symptoms,  which  we 
comprise  under  the  name  of  blennorrhagic  rheumatism,  is  blennorrhagia 
itself  ;  but  I  am  quite  of  M.  Fereol's  opinion,3  that  M.  Fournier  goes  too 
far  in  ascribing  it  so  unhesitatingly  to  catheterism,  and  saying,  that  if  we 
give  him  a  sound  he  will  produce  gonorrhceal  rheumatism.  I  have  repeat- 
edly passed  both  the  bougie  and  catheter  in  gonorrhoea  ;  I  have  drawn  off 
the  water  day  after  day,  have  used  the  long  syringe,  and  even  the  caustic- 
holder,  in  this  disease  without  any  such  result ;  whereas  the  symptoms 
ensuing  from  the  employment  of  the  catheter  acting  unfavorably  are  far 
more  menacing — shiverings,  quick  pulse,  great  prostration  and  anxiety, 
loss  of  appetite  and  formation  of  pus.  Of  course  the  same  objection  ap- 
plies to  the  statement 4  of  M.  Demarquay,  that  very  often  after  the  use  of 
the  catheter  pain  appears,  ripening  into  a  veritable  arthritis,  which  in  a 
few  rare  instances  may  take  on  all  the  characters  of  the  gonorrhceal  form. 
M.  Mauriac  runs  to  as  great  an  extreme.  He  considers 5  that  two  cases, 
which  he  relates,6  show  that  gonorrhceal  rheumatism  can  be  evoked  by 
simple  purulent  running  being  set  up  in  the  urethra  through  the  use  of 
nitrate  of  silver  injections.  The  evidence  is  among  the  most  extraordin- 
ary I  ever  heard  of.  In  the  first  case  the  patient  never  had  any  urethral 
discharge,  and  it  is  not  shown  that  he  ever  used  injections ;  he  was  merely 
suffering  from  syphilis.  Besides,  unless  the  urethra  is  affected  with  un- 
cured  gonorrhoea,  nitrate  of  silver  injections  would  not  set  up  purulent 
running  for  more  than  a  few  hours  and  in  a  very  mild  form.  The  second 

1  Gazette  Hebdomadaire,  pp.  42,  106.     1867.  2  Ibid.     1866  and  1867. 

3  Ibid.,  p.  44.     1867.  «  Voelker:  Op.  citat.,  p.  125. 

6  Gazette  des  Hupitaux,  p.  298.     1875.  6  Ibid.,  p.  274. 


240  ON    GONORRHOEA. 

patient  had  balanitis  and  then  gonorrhoea,  which  M.  Mauriac  maintains 
was  simply  urethritis  provoked  by  the  same  injections. 

M.  Pidoux  also  points  out l  differences  in  the  course  run  by  gonor- 
hoeal  rheumatism.  Thus,  for  instance,  when  the  latter  attacks  the  radio- 
carpal  articulation,  the  swelling  all  at  once  attains  such  a  height  that  the 
folds  and  projections  disappear,  and  the  narrowing  at  the  wrist  is  lost, 
while  the  diameter  through  from  front  to  back  almost  equals  that  from 
side  to  side.  The  synovial  membrane  is  thickened,  the  extremities  swell, 
and,  if  the  case  be  refractory,  atrophy  is  set  up  in  the  muscles  inserted 
above  and  below  the  articulation.  Even  when  the  gonorrhoea  is  quite 
recent,  the  patient  has  a  pale,  fatigued  look,  a  change  which  I  have  not 
noticed  ;  finally,  he  tells  us  that  this  form  of  gonorrhoea  brings  in  its  wake 
obstinate  swellings  of  the  inguinal  and  submaxillaoy  glands,  sebaceous 
acne,  pityriasis,  impetigo  of  the  scalp,  coryza,  and  crusted  eruptions  on  the 
lips,  not  one  of  which  have  I  seen. 

According  to  M.  Laboulbene,"  there  is  a  wide  distinction  between  the 
pathological  products  of  this  and  the  common  form.  He  twice  punctured 
the  knee-joint  of  a  young  man  suffering  under  gonorrhoea!  rheumatism. 
The  liquid  obtained  was  yellow,  viscous,  purulent,  and  much  charged  with 
fibrinous  matter.  It  contained  a  largish  proportion  of  pus-globules  and 
blood-globules,  but  no  mucine,  whereas  the  fluid  of  simple  synovitis  and 
ordinary  arthritis  yields  abundance  of  this  substance.  The  blood,  too,  does 
not  show  the  buffy  state  seen  in  the  common  form.  M.  Kollet  bled  five 
patients  suffering  from  gonorrhoea!  rheumatism.3  In  one  of  them  six  ar- 
ticulations were  affected,  yet  the  clot  did  not  present  any  inflammatory 
coat.  Of  the  other  four  one  had  four  joints  attacked,  the  others  two  and 
three  ;  but  the  blood  was  not  buffed  in  one  of  them.  In  twenty-nine  cases 
Dr.  Pye-Smith  found 4  the  urine  free  from  albumen  or  sugar,  except  in  one 
where  transient  glycosuria  was  present. 

Fournier  found  that  out  of  fifty-two  cases  the  joints  were  not  affected 
in  fifteen,  and  that  in  sixteen  cases  out  of  fifty-two  the  disease  was  limited 
to  one  locality.  It  is  to  be  observed,  however,  that  he  ranks  eye  affections 
among  the  manifestations  of  this  rheumatism,  and  some  instances  of  it  are 
counted  among  the  number  limited  to  one  spot.  But  he  finds  the  gonor- 
rhoea! form  more  often  restricted  to  a  few  places  than  to  one,  which  does 
not  accord  with  my  experience,  while  it  does  not,  like  common  rheumatism, 
attack  several  joints  at  once. 

Divisions. — He  recognizes  four  divisions  of  this  affection  :  1.  That  of 
hydrarthrosis,  which  is  very  rare.  2.  The  rheumatic  or  arthritic  form. 
3.  Simple  arthralgia,  in  which  there  are  joint  pains,  leaving  the  joint,  how- 
ever, unaffected  ;  showing  no  tenderness  or  tumefaction  ;  no  creaking  is 
heard  on  moving  the  joint,  and  the  part  'is  not  very  sensitive  to  pressure, 

1  Gazette  Hebdomadaire,  p.  822.     1866.  s  Ibid. ,  p.  475.     1871. 

4  Revue  Mensuelle,  p.  66.     1878.  4  Op.  citat.,  p.  342. 


TREATMENT.  241 

sometimes  even  indolent.  He  has  seen  this  form  in  the  knee,  wrist, 
shoulder,  metatarsus,  articulations  of  the  phalanges,  and  temporo-maxillary 
joint.  4  The  knotty  form,  which  is  accompanied  by  deformity  of  the 
joint  as  in  knotty  (noueux)  rheumatism  or  gout.  This  attacks  not  only  the 
joint,  but  also  periarticular  fibrous  tissue,  and  even  periosteum,  thus  in- 
ducing both  periostitis  and  periostosis,  or  inflammatory  exudation,  the 
latter  taking  its  origin  in  the  tissue  (frame)  of  the  periosteum,  painful  at 
first  but  gradually  assuming  the  shape  of  an  indolent,  flattened  deposit, 
so  adherent  to  the  bone  as  to  be  motionless.  He  has  seen  this  variety  in 
the  carpo-metacarpal,  metatarso-phalangeal  articulations,  and  in  the  great 
toe. 

He  has  noticed  that  non-articular  parts  are  more  frequently  attacked  than 
articular,  and  that  the  affection  may  fasten  upon  more  points  numerically 
than  common  rheumatism  would.  In  the  list  of  manifestations  he  includes 
rheumatism  of  the  tendinous  and  mucous  bursae,  and  muscles,  simple  pains, 
ophthalmia,  neuralgia,  as  seen  for  instance  in  the  sciatica  elsewhere  de- 
scribed by  him,  and  phlegmasia  of  the  periosteum  ;  but  rejects  the  lesions 
of  internal  organs,  such  as  those  of  the  pleura,  endocardium,  pericardium, 
as  also  those  of  the  venous  system,  the  rachidian  and  cerebral  meninges, 
liver,  salivary  glands,  etc. 

Once  in  every  three  or  four  cases  gonorrhceal  rheumatism  will  appear 
in  other  parts  than  the  joints,  these  other  parts  including,  it  is  to  be  re- 
membered, the  'eye.  More  persons  are  affected  with  the  articular  than 
with  the  non-articular  form,  the  proportion  being  for  the  former  about 
thirty-seven  out  of  fifty-two  of  all  cases.  This  is  seemingly  in  direct  con- 
tradiction to  what  has  just  been  said,  but  he  explains  the  discrepancy  by 
pointing  out  that  the  number  of  attacks,  or  rather  of  points  assailed,  is 
greater  in  a  case  of  the  non-articular  kind.  The  arthritic  variety  is  not 
confined  to  one  joint,  as  is  often  stated ;  he  only  found  it  so  sixteen  times 
out  of  the  thirty-seven  cases  just  spoken  of.  Consequently  he  does  not  ac- 
cept this  as  the  distinguishing  feature  between  gonorrhceal  and  common 
rheumatism  ;  the  great  peculiarity  of  the  former  is  that  the  disease  does 
not  attack  many  joints  at  the  same  time,  and  never  makes  such  a  general 
invasion  of  these  structures  as  we  may  see  in  the  non-specific  form. 

Among  the  unusual  places  where  Fournier  has  noticed  gonorrhceal 
rheumatism,  ai*e,  in  addition  to  the  temporo-maxillary  articulation  as  al- 
ready mentioned,  three  cases  of  which  have  also  been  reported  by  Padova, ' 
the  spine  of  the  scapula,  insertion  of  the  tendon  of  the  patella  into  the 
tuberosity  of  the  tibia,  the  carpo-metacarpal  joints,  and,  in  two  cases,  at 
spots  on  a  level  with  the  spinal  apophyses  of  the  dorsal  vertebrae  ;  locali- 
ties in  which  I  believe  it  is  most  rare  to  meet  with  painful,  isolated  rheu- 
matism of  the  common  type.  The  proportion  of  those  affected  with  gonor- 


1  Giornole  italiano,  an.  viii.,  p.  231.     1873. 
16 


242  OK    GONORRH(EA. 

rhoeal  rheumatism,  to  that  of  gonorrhoea  patients,  is  put  down  by  Fournier 
at  1  in  62,  or  31  in  1,912,  while  Mr.  Bond  estimates  the  proportion  at  1  in 
10,  a  number  vastly  in  excess  of  what  I  have  seen.  The  tendency  to  this 
affection  seems  to  increase  and  decline  much  more  rapidly  than  that  toward 
orchitis.  Out  of  56  cases  it  began  in  the  1st  week  in  4,  the  2d  in  8,  the  3d 
in  18,  the  4th  in  16,  the  5th  in  4,  the  6th  in  3,  the  7th  and  8th  in  3.1  In 
my  own  practice  the  proportion  of  cases  in  the  first  and  second  weeks  has 
been  decidedly  larger. 

Gonorrhceal  Synovitis. — Before  closing  entirely  the  subject  of  the  divi- 
sions of  this  affection,  it  will  be  desirable  to  say  a  few  words  about  the 
synovia!  form,  mentioned  by  that  admirable  observer,  Fournier,  and  no- 
ticed since  very  fully  by  some  of  the  French  writers.  What  little  I  have 
to  lay  before  the  reader  is  taken  from  a  clinical  lecture  by  M.  Lasegue,2  an 
analytical  review  of  this  and  of  M.  Maymou's  views,3  and  from  the  oiiginal 
memoirs  by  the  last-named  author.4  This  gentleman  having  pointed  out 
how  recent  our  knowledge  of  gonorrhoeal  synovitis  is,  and  that  M.  Rollet 
was  the  first  person  who  enforced  the  recognition  of  it,  says  that  according 
to  a  list  drawn  up  by  M.  Fournier,  it  forms  about  a  fourth .  of  the  cases 
classed  as  gonorrhoeal  rheumatism.  The  attack  may  begin  at  the  end  of 
the  first  week,  but  usually  comes  on  toward  the  commencement  of  the 
third.  It  may,  however,  appear  as  late  as  several  months  after  the  gonor- 
rhoea first  showed  itself,  and  is  then  generally  associated  with  some  excess 
in  diet,  or  connection,  which  has  exasperated  the  running.  There  are  no 
prodromata ;  the  patient  may  be  taken  with  a  shivering  fit,  but  this  may 
also  be  absent.  The  first  onset  of  pain  is  usually  in  a  joint.  This  gener- 
ally lasts  a  few  hours,  and  then  other  pains,  equally  fleeting,  attack  one 
part  after  another,  till  at  last  the  disorder  fastens  on  one  or  more  of  the 
tendinous  sheaths.  In  one  case  6  the  pain  began  in  the  right  knee  and  was 
succeeded  the  next  day  by  pain  in  the  sacro-iliac  articulations,  again  in  its 
turn  followed  by  pain  in  the  articulations  of  the  cervical  vertebrae.  Then 
pains,  just  as  fugitive,  invaded  successively  the  articulations  of  the 
shoulder,  elbow,  and  right  knee  again,  where  they  lasted  three  days. 
Finally  the  pain  quitted  this  site,  to  settle  definitely  on  the  extensor  ten- 
dons of  the  last  three  toes  of  the  left  foot. 

Along  with  the  pains  come  a  feeling  of  not  being  well  and  loss  of  appe- 
tite. The  tongue  indicates  fever  ;  in  one  patient  it  was  coated  as  in  a  gouty 
person.  Twice  he  noticed  vomiting.  Swelling  with  pastiness  of  overlying 
tissues,  sense  of  fluctuation  in  affected  sheath,  and  a  rose  or  rose-violet 
color  of  the  skin  may  accompany  the  attack.  M.  Maymou  could  not  make 
out  whether  the  outbreak  of  synovitis  influences  the  urethral  affection  in 

1  Revue  Mensuelle,  p.  199.     1878.  -  Gazette  des  Hopitaux,  p.  66.     1876. 

3  Ibid.,  p.  113.         4  Archives  Generates  de  Medecine,  tome  ii.,  p.  555.    1875. 
6  Ibid.,  p.  656. 


TREATMENT.  %  243 

women,  but  thinks  that  in  men  this  is  diminished,  though  not  very  sensibly ; 
in  a  great  number  of  cases  it  remains  intact  He  distinguishes  three  kinds 
of  pain.  I.  That  which  takes  place  independently  of  any  movement  or 
pressure.  2.  That  which  is  elicited  by  pressure  ;  and  3.  That  induced  by 
movements  communicated  to  the  articulations.  The  first  variety  is  very  se- 
vere during  the  first  two  or  three  days,  and  is  accompanied  by  night  exacer- 
bations ;  it  soon,  however,  ceases  during  the  day,  and  is  felt  only  at  night. 
Finally  it  generally  dies  out  after  the  first  week.  Pressure  increases  pain 
over  a  track  corresponding  to  the  affected  tendinous  sheath.  When  care 
is  taken  to  place  the  tendons  in  a  relaxed  position,  movement  is  not  pain- 
ful, but  very  much  so  when  these  are  stretched  ;  M.  Lasegue  particularly 
dweUs  upon  this  feature.  Gonorrhoeal  synovitis  may  attack  a  great  num- 
ber of  tendons  ;  those  it  fastens  upon  by  preference  are  the  extensors  of 
the  fingers  and  adductor  of  the  thumb,  the  tendons  of  the  toes,  those  at 
the  lower  end  of  the  gracilis,  sartorius,  and  semi-tendinosus,  forming  what 
the  French  cah1  the  goose-foot  (patte  d'oie),  and  of  the  biceps  of  the  arm 
and  thigh. 

When  the  malady  has  fixed  upon  a  tendinous  sheath,  the  first  phenom- 
ena noticed  are  swelling  and  sense  of  false  fluctuation  ;  then  follows  a  rosy 
or  violet-red  hue  of  the  skin.  The  rosy  tint  is  usually  on  a  level  with  some 
of  the  parts  corresponding  to  the  affected  tendinous  sheath  ;  it  may  appear 
in  patches.  Generally  but  not  always  these  parts  are  most  painful  on 
pressure.  There  is  always  a  rather  extended  zone  of  oedema  round  a  part 
affected  with  pastiness,  tumefaction,  and  inflammatory  swelling  of  the  skin  ; 
and  this  cedema  is  more  marked  in  proportion  to  the  severity  of  the  pain, 
and  the  earliness  of  the  date  at  which  this  appeared  after  the  gonorrhoea 
showed  itself. 

Gonorrhceal  synovitis  generally  lasts  only  from  four  to  six  weeks,  and 
is  one  of  the  mildest  affections  of  this  kind,  milder  even  than  ordinary 
rheumatism.  Three  times  out  of  four  or  five  cases  M.  Maymou  satisfied 
himself  that  the  tendons  returned  almost  completely  to  their  normal  state. 
In  one  case  he  observed  that  after  the  malady  had  lasted  the  usual  time, 
the  action  of  the  tendons  was  still  extremely  restricted,  but  in  this  in- 
stance the  affection  was  complicated  with  arthritis.  M.  Fournier,1  in  three 
cases  out  of  ten  which  he  observed,  saw  the  complaint  take  on  a  very 
different  character  from  what  is  generally  noticed,  there  being  tumefaction 
with  a  phlegmonous  look  and  erysipelatous  hue,  accompanied  by  excessive 
pain.  Both  it  and  the  arthritic  form  may,  according  to  M.  Quinquaud,  be 
complicated  with  erythema  nodosum.  According  to  M.  Lasegue  this 
affection,  the  duration  of  which  he  fixes  at  about  six  weeks,  is  sometimes 
only  an  early  stage  of  a  more  serious  and  lasting  complaint.  The  painful 
.spot  does  not  improve,  and  then,  a  little  later,  the  whole  ligamentous  ap- 

1  Archives  Generates  de  Medecine,  tome  ii. ,  pp.  664  and  666. 


244  ON    GONORRHOEA. 

paratus  is  affected  and  becomes  stiff.  In  a  third  variety,  the  articulating- 
surfaces  are  assailed.  M.  Lasegue  points  out,  as  a  pathognomonic  sign  of 
this  form  of  arthritis,  wasting  of  the  upper  parts  of  any  limbs  it  may 
attack,  not  the  wasting  due  to  inaction,  but  a  real  atrophy  beginning  with 
the  affection  itself  ;  it  is  seen,  however,  only  in  the  second  variety,  but 
then  constitutes  a  mark  distinguishing  this  widely  from  the  common  form. 
M.  Mayinou  considers  that  the  arthritic  form,  especially  when  it  attacks 
the  knee  and  wrist,  often  for  days  or  even  months  after  occasions  patients 
some  difficulty  in  executing  certain  movements  with  the  affected  tendons. 
He  has  never  seen  the  synovial  affection  induce  the  various  morbid  effects 
(inftrmites),  which  result  from  the  others. 

Gonorrhoea!  Sciatica. — Perhaps  it  will  be  better  to  take  this  affection 
here,  as  it  seems  clearly  to  be  gonorrhoeal  rheumatism  affecting  the  sciatic 
nerve.  I  believe  it  was  first  noticed  by  Sir  Everard  Home,1  who  describes 
two  cases.  In  one  attack  the  first  patient  had,  after  a  recent  gonorrhoea, 
sciatica  attended  with  spasms  in  the  lower  extremity,  the  most  severe  that 
can  be  imagined,  followed  by  a  painful  affection  of  the  back  and  knees.  In 
the  second  he  had  the  sciatica  worse  than  ever,  the  spasms  extending  even 
to  the  intercostal  muscles.  The  patient  was  confined  to  bed  nearly  four 
months,  and  "his  life  was  in  imminent  danger."  In  the  second  case  the 
patient  three  times  had  sciatica  from  gonorrhoea,  the  first  time  two  or 
three  months  after  the  cessation  of  the  latter.  The  second  of  these  attacks 
had  lasted  two  years  when  he  caught  the  third  infection.  The  credit  of 
thoroughly  investigating  the  affection  belongs  to  M.  Fournier.  As  long  ago 
as  1867  he  had  collected  ten  cases.2  The  affection  is  as  distinct  from  com- 
mon sciatica  as  gonorrhoeal  rheumatism  from  the  ordinary  kind,  being 
marked  by  great  suddenness  of  attack  and  rapid  subsidence,  abatement 
appearing  in  three,  four,  or  five  days  ;  by  its  assailing  persons  suffering 
under  gonorrhoeal  rheumatism  and  rapidly  becoming  intense  ;  by  its 
sometimes  alternating  with  gonorrhoeal  rheumatism  and  yielding  very 
quickly  to  cupping  and  narcotic  applications,  his  experience  being  thus 
utterly  opposed  to  Home's ;  and  by  its  returning  with  a  fresh  infection. 
Two  of  Fournier's  patients  twice  had  it  after  gonorrhoea.  A  carefully  pre- 
pared abstract  of  M.  Fournier's  views  will  be  found  in  the  Medical  Times 
for  1868.3 

Up  to  the  date  of  his  memoir  Fournier  considered  that  there  had  not 
been  recorded  one  authentic  case  of  gonorrhoeal  arthritis  ending  in  sup- 
puration of  a  joint.  He,  however,  gives  one  where  this  took  place  ;  the 
elbow  was  the  part  affected,  but  the  formation  may  have  been,  in  some 
measure,  due  to  intercurrent  typhoid  fever,  by  which  the  patient  was  cut 
off.  Since  then  three  cases  have  been  collected  from  French  writers  by 

1  Treatment  of  Strictures  in  the  Urethra,  vol.  ii. ,  p.  273.     1803. 
•Gazette  Hebdomadaire,  p.  123.     1867. 
"Vol.  ii.,  p.  647. 


TREATMENT.  245 

M.  Talamon. '  lu  two  of  these  the  suppuration  occurred  in  the  elbow  ;  in 
the  third  patient,  a  woman,  it  took  place  in  the  knee  and  afterward  in  the 
hip.  A  fifth  case  is  reported  in  Holmes's  Surgery.2  The  patient,  a  male, 
age  not  stated,  was  attacked  with  great  pain  and  swelling  in  the  right 
knee-joint.  In  a  few  days  the  lower  part  of  the  thigh  became  filled  with 
matter  which  had  escaped  from  the  distended  synovia!  membrane.  On 
amputating  the  limb  the  joint  was  found  to  be  thoroughly  disorganized. 

The  arthralgic  form  does  not  seem  to  be  accompanied  by  any  patho- 
logical changes  in  the  joints  ;  it  is  usually  seen  in  the  course  of  recently 
contracted  gonorrhoea,  along  with  other  signs  of  specific  rheumatism,  such 
as  synovitis,  painful  inflammation  and  ophthalmia,  or  it  may  accompany 
an  old  gleet  without  any  other  manifestation. 

I  proceed  to  another  set  of  facts,  showing  the  exceptional  tenacity 
sometimes  manifested  by  this  disorder.  A  young,  healthy-looking  man 
applied  to  me  with  chronic  gonorrhoeal  rheumatism,  which  had  incapaci- 
tated him  for  four  successive  winters  from  doing  any  work.  It  was  prin- 
cipally seated  in  the  sole  of  the  foot,  and  the  pain  was  so  severe  that  he 
ccfald  not  stand  more  than  half  an  hour.  If  he  attempted  to  exceed  this 
time,  a  hot  burning  pain  attacked  every  part  on  which  the  weight  of  the 
body  rested,  and  this  soon  became  so  severe  as  to  compel  him  to  lie  down. 
Even  when  resting  the  pain  grew  so  excessive  toward  night  that  he  could 
not  wear  a  boot.  He  had  wandered  about  from  one  surgeon  to  another, 
till  at  last,  from  sheer  poverty,  he  was  obliged  to  enter  a  hospital,  where 
he  remained  eight  weeks.  He  came  out  as  bad  as  he  went  in.  In  this 
case  the  pains  began  three  days  after  the  appearance  of  the  gonorrhoea, 
and  resisted  three  separate  salivations  earned  so  far  as  to  loosen  the  teeth. 
What  else,  he  had  used  he  could  not  tell ;  but  I  gathered  from  his  acconnt 
that  galvanism,  clamps  to  the  feet,  and  mustard-poultices  had  been  tried. 
Second  case  very  similar  and  almost  as  severe. 

In  a  third  case  the  patient  was  attacked  so  severely  as  to  be  confined 
to  his  room  nearly  eighteen  months,  under  the  care  of  a  surgeon  who 
really  seemed  to  have  done  almost  everything  that  could  be  done. 
Amongst  other  things,  the  patient  took  lemon-juice  in  such  quantities  that 
he  used  to  buy  lemons  in  Covent  Garden  by  the  hundred.  A  long  and 
most  tedious  recovery  left  him  very  lame,  both  in  his  hands  and  feet. 
About  six  years  afterward  he  contracted  another  discharge,  for  which  he 
placed  himself  under  my  care,  and  immediately  another  attack  of  rheuma- 
tism fastened  upon  him.  For  weeks  he  could  scarcely  turn  in  his  bed, 
and  at  the  lapse  of  four  years  was  still  suffering.  I  afterward  heard  that 
he  had  recovered. 

In  a  fourth  case,  seeing  within  the  first  day  or  two  that  signs  of  rheu- 
matism were  showing  themselves,  I  closely  questioned  the  patient  as  to 

1  Revue  Mensuelle,  p.  71.     1878.  s  Vol.  iv.,  p.  35.     1870. 


246  ON    GONORRHOEA. 

whether  he  had  ever  suffered  from  this  complaint  or  not,  and  learning- 
that  he  had,  I  begged  of  him  to  let  me  take  the  most  energetic  measures 
at  once.  Instead  of  this  he  went  down  into  the  country  and  thoroughly 
neglected  it.  Kheumatism  of  the  most  violent  character  at  once  assailed 
both  thighs  and  both  knee-joints,  extending  seemingly  up  the  sheath  of 
the  spinal  cord,  as  when  I  next  saw  him,  a  few  months  after,  he  could  not 
stand  steadily,  and  was  almost  paralyzed  from  the  loins  downward. 
Even  then  nothing  could  induce  him  to  be  prudent,  and  in  this  shattered 
state,  a  perfect  wreck  to  all  appearance,  he  contracted  another  discharge. 
The  result  was  an  immediate  exacerbation  of  the  rheumatism,  which  had 
remained  bad  all  the  time.  The  paralysis  also  rapidly  gained  ground 
from  this  time,  and  when  I  last  saw  him,  a  very  few  weeks  after  the  first 
appearance  of  the  discharge  just  spoken  of,  he  was  unable  to  get  up  even 
two  stairs,  and  could  not  stand  at  all.  All  control  over  the  rectum  and 
nearly  all  over  the  bladder  was  lost. 

In  the  fifth  case  the  patient,  a  fine,  strong,  healthy,  and  very  active  man, 
who  certainly  would  not  have  allowed  any  trifle  to  lay  him  up,  was  at- 
tacked with  this  rheumatism  in  the  shoulder,  almost  directly  after  the 
gonorrhoea  showed  itself,  in  such  a  violent  form  that  he  was  four  months 
confined  to  bed,  though  his  surgeon,  a  gentleman  at  the  head  of  the  sur- 
gical department  of  a  large  hospital,  showed  every  attention  to  the  case. 

Another  patient,  who  had  already  suffered  from  periostitis  in  the  tibia, 
had  an  attack  of  rheumatism  from  a  slight  discharge.  It  was  subdued, 
but  the  treatment  was  broken  off  before  anything  like  a  complete  cure  was 
effected.  Soon  after  the  rheumatism  appeared  he  had  complained  of  an 
uneasy  feeling  in  the  site  of  the  periostitis,  and  shortly  afterward  this  re- 
turned with  such  severity,  that,  after  nearly  losing  his  leg,  he  was  glad  to 
escape  with  two  abscesses  in  the  tibia  and  a  serious  illness  of  several 
months'  duration.  I  think  it  may  safely  be  said  that  ordinary  rheuma- 
tism in  such  a  shape  does  not  exhibit  this  almost  unconquerable  obstinacy. 

Gonorrhceal  Rheumatism  in  Women. — My  own  experience  is  that  this- 
affection  is  excessively  rare  in  the  other  sex,  but  quite  as  severe  as  in  men. 
One  of  the  worst  cases  that  ever  came  under  my  care  was  that  of  a  lady 
infected  by  her  husband,  the  pain,  which  was  of  the  most  violent  character, 
appearing  before  the  discharge.  One  case  in  the  female  is  reported  by 
Mr.  de  Meric,1  one  in  the  sixteenth  volume  of  "Guy's  Hospital  Reports,"  ' 
and  there  are  two  cases  in  the  eighteenth  volume.3  A  case  is  reported  by 
Mr.  Hardy. 4  Dr.  Angelo  Scarenzio  saw  three  cases  in  women,  all  accompany- 
ing gonorrhoea  of  the  urethra,6  and  M  Quinquaud  also  relates  three.  In 
a  space  of  about  two  years  M  Fournier  saw  seven  cases  in  the  female,  and 
does  not  consider  the  disease  so  very  rare  in  women,  and  M.  Brun,  out  of 

1  British  Medical  Journal,  vol.  i. ,  p.  335.     1867.  2  Third  series,  p.  568. 

3  Page  441.  *  Dublin  Quarterly  Journal,  voL  xlvi.,  p.  241. 

6  Op.  citat.,.  loc.  citat. 


TREATMENT.  247 

twenty  cases,  found  thirteen  in  women. '  Duplay  and  he  say  2  it  is  as  fre- 
quent in  woman  as  in  man.  Davies-Colley,  in  twelve  cases  of  acute  gon- 
orrhceal  rheumatism,  found  nine  in  women. 

M.  Eicord  has  always  taught  that  it  is  only  found  with  urethral  gon- 
orrhoea, but  I  have  seen  a  very  bad  form  of  it  accompany  obstinate  gonor- 
rhoeal  vaginitis,  the  urethra  showing  nothing  on  repeated  examination  ; 
and  M.  Brun  mentions  a  very  similar  case,  there  being  nothing  wrong  with 
the  urethra,  though  there  was  a  notable  quantity  of  pus  in  the  culs-de-sac. 

Complications.  a.-b.  Gonorrhceal  Endocarditis  and  Pericarditis. — This 
form  of  rheumatism  is  in  its  turn  complicated  by  or  leads  to  diseases  of  a 
formidable  character.  Foremost  among  these  stand  the  affections  at  the 
head  of  this  paragraph.  The  first  case  of  this  nature  ever  reported,  so  far 
as  I  am  aware,  is  by  M.  Brandes.3  The  patient  had  gonorrhoea  with  rheu- 
matism, on  which  followed  endocarditis,  marked  by  prolonged  and  rough 
state  of  the  first  sound.  The  second  is  reported  by  the  same  author,  but 
was  communicated  to  him  by  M.  Lehmann  ;  the  patient  was,  under  similar 
circumstances,  attacked  by  pericarditis  with  palpitation  and  extension  of 
pericardial  dulness.  In  the  third,  endocarditis,  reported  by  M.  Hervieux,4 
there  were  present  fever,  cardiac  palpitation,  and  bellows  sound  at  the  base. 
The  fourth  case  was  also  one  of  endocarditis  ;  it  is  given  by  M.  Tixier  * 
from  the  practice  of  M.  Lorain.  There  was  cardiac  complication  with 
bellows  sound  ;  also  disturbance  of  circulation,  succeeded  by  signs  of 
mitral  insufficiency,  with  considerable  hypertrophy,  ah1  following  upon 
blennorrhagia  with  rheumatic  pain.  Later  on  came  asystolism,  succeeded 
by  death  from  cardiac  disease.  Fifth  case,  pericarditis,  is  also  by  M. 
Tixier,6  but  observed  by  himself.  The  patient  suffered  from  gonorrhoea 
and  gonorrhoea!  rheumatism  ;  at  the  end  of  about  seven  weeks  these  began 
to  be  complicated  by  general  feeling  of  being  ill,  fever  at  night,  pericardial 
anxiety  and  effusion,  with  deadening  of  heart-sounds.  The  sixth  case, 
endocarditis,  is  communicated  by  M.  Voelker ; '  the  phenomena  enumerated 
are  blennorrhagia,  rheumatism,  and  doubling  of  the  first  sound  at  the  base  ; 
not  very  strong  evidence.  The  seventh  case,  endocarditis,  is  likewise  taken 
from  Voelker ;  *  symptoms,  blennorrhagia,  rheumatism  ;  at  the  end  of  four 
weeks  pain  at  apex,  murmur  with  first  sound,  which,  however,  disappeared 
entirely  in  three  weeks.  The  eighth  case,  pericarditis,  is  by  M.  Lacas- 
sagne  ; 9  it  is  very  fully  and  carefully  related  and  well  worth  studying. 
The  affection  began  with  gonorrhoea.  Two  days  after  admission  the 
patient  was  attacked  with  constrictive  pains  at  the  base  of  the  chest,  acute 
pain  at  apex  of  heart,  characteristic  shivering,  extension  of  dulness  and 

1  Op.  citat. ,  p.  16.       2  Archives  Generates  de  Medecine,  tome  i. ,  p.  545.     1881. 

3  Op.  citat. ,  p.  262.  *  Gazette  Medicale,  p.  354.     1858. 

5  Op.  citat.,  p.  58.  6  Ibid.,  p.  82. 

1  Op.  citat.,  p.  110.  8  Morel,  op.  citat.,  p.  16. 

9  Archives  Generates  de  Medecine,  tome  i.,  p.  23.     1872. 


248  ON    GOlSrORRH(EA. 

tumultuous  rapid  sound,  bruit  de  rappel.  There  was  no  rheumatism  in 
this  case.  The  patient  left  with  the  systolic  murmur  more  marked  than 
natural 

The  ninth  case,  endocarditis,  is  by  M.  Desnos. '  The  patient,  while  m 
suffering  from  gonorrhoea,  complained  of  feeling  ill.  After  a  few  days  of 
this  the  discharge  lessened  considerably.  He  was  then  seized  with  shiver- 
ings,  intense  fever,  great  pain  in  the  lower  extremities,  settling  in  the 
knees  and  hips,  yielding  after  a  few  days  and  then  reappearing,  but  with 
less  intensity,  in  the  shoulder  and  neck.  After  suftmng  in  this  way  fifteen 
days  at  home  in  bed,  he  was  admitted  into  the  hospital,  when  it  was  found 
that  the  pain  in  the  joints  had  almost  disappeared  ;  the  left  knee  had, 
however,  increased  in  size,  and  there  was  a  small  quantity  of  fluid  in  the 
joint.  There  was  a  bellows  murmur  at  base  with  first  sound,  and  a  weaker 
sound  at  the  apex,  which  was  clearly  a  repetition  of  the  first  bellows  sound 
at  the  base,  the  latter  being  indicative  of  aortic  narrowing.  Ten  days 
after  admission  he  was  seized  with  alarming  syncope,  became  suddenly  pale 
and  threw  back  his -head;  the  pupils  were  dilated  and  the  eyes  convulsively 
turned  upward.  The  respiration  grew  quick  and  then  slackened  ;  the 
beating  of  the  heart  became  weak,  and  was  next  suspended  for  twenty-five 
to  thirty  seconds.  After  this  the  patient  gradually  recovered,  clonic  con- 
vulsions ensuing  for  some  seconds.  Attacks  of  this  kind  increased  in  fre- 
quency till  they  got  to  be  as  many  as  twelve  in  an  hour ;  then  they  declined 
and  gradually  ceased.  In  an  interval  of  freedom,  examination  of  the  heart 
showed  rasping  sound  at  base,  pointing  to  insufficiency  of  aortic  orifice  ; 
the  patient  left  with  the  abnormal  sounds  lessened  but  still  present. 

After  this  comes  a  case  of  endocarditis  by  M.  Marty,  forming  part  of  a 
valuable  memoir 2  on  this  affection.  The  case  is  detailed  at  great  length, 
the  readings  of  the  temperature,  etc.,  being  fully  given.  The  patient  was 
admitted  for  gonorrhoea.  Five  weeks  after  entry  he  was  seized  with  violent 
shivering,  intense  cephalalgia  and  sleeplessness.  A  few  days  later  the 
heart-sounds  were  found  to  be  strong,  and  three  days  after  this  a  rasping 
systolic  sound  was  heard  at  base.  Case  treated  with  blistering,  nitrate  of 
potass,  and  tincture  of  digitalis.  Vomiting,  however,  and  anorexia  super- 
vened, and  were  followed  by  palpitation,  pre-sternal  pain,  weariness  and 
backache,  for  which  quinine  and  digitalin  pills  were  ordered.  Considerable 
amelioration  took  place,  but  at  the  close  of  the  narrative  the  discharge  had 
returned,  the  palpitation  was  still  pronounced,  and  the  sound  had  softened 
little.  There  was  no  rheumatism. 

Subsequently  to  the  appearance  of  M.  Marty's  memoir  another  case, 
endocarditis,  was  reported 3  from  the  practice  of  M.  Desnos.  The  patient, 


'Progres  medical,  December   12,  1874.     Quoted  by  Marty,  Morel,  etc. 

2  Archives  Generates  de  Medecine,  tome  ii.,  p.  660.     1876. 

3  Gazette  des  Hopitaux,  p.  1067.     1877. 


TKEATMENT.  249 

a  man,  age  not  stated,  was  admitted  into  La  Pitie  for  acute  bronchitis. 
After  a  few  days  he  complained  of  sharp  pain  in  the  left  shoulder,  and,  as 
it  began  to  abate,  of  pain  in  the  left  sterno-clavicular  articulation.  He  was 
then  found  to  have  gonorrhoea ;  he  had  never  before  had  rheumatism.  The 
pain  proved  obstinate,  and  during  treatment  the  patient  was  suddenly 
seized  with  rather  violent  dyspnoea  and  palpitations,  the  bronchitis  having 
about  this  time  somewhat  improved.  The  action  of  the  heart  became 
tumultuous  and  irregular,  and  at  the  apex  a  trilling  sound,  bruit  de  roule- 
ment,  was  heard,  indicative  of  narrowing  and  insufficiency  of  the  mitral 
valve.  The  patient  lost  strength,  and  fever  appeared  with  great  thermo- 
metrical  oscillations  ;  finally  asystolism  came  on,  defying  all  the  efforts  of 
M.  Desnos  to  conquer  it.  In  proportion  as  the  radial  pulse  became  weak 
and  very  small,  so  did  the  inferior  extremities,  and  toward  the  last  even  the 
hands,  become  cedematous,  there  being  however  no  albuminuria.  The 
double  bronchitis,  which  had  for  a  time  improved,  now  relapsed  and  took 
on  the  form  of  cedematous  congestion,  revealing  itself  by  dyspnoea  and 
numerous  subcrepitant  rattles  on  both  sides  of  the  chest  ;  the  asphyxia, 
which  had  crept  on  slowly  at  first,  made  rapid  progress  now  and  carried 
the  patient  off  in  about  a  month  from  the  date  of  his  admission.  At  the 
autfpsy  it  was  found  that  both  lungs  were  red,  not  collapsing  when  the 
chest  was  opened,  and  exuding  on  pressure  a  pale  red  liquid.  The  pericar- 
dium was  healthy,  but  the  mitral  valve  presented,  at  a  few  millimetres 
from  the  free  edge  of  its  anterior  process,  a  vegetation  the  size  of  a  lentil, 
calculated  to  hamper  the  play  of  the  valve  and  explain  the  trilling  sound 
heard  during  life  ;  there  was  also  a  grayish  vegetation  closely  adhering  to 
one  of  the  aortic  valves  by  the  inferior  surface,  while  on  the  superior  aspect 
there  was  another  vegetation  not  less  adherent,  of  the  same  size  and  of  a 
grayish  hue.  M.  Desnos  considers  that  these  vegetations  were  not  alto- 
gether the  result  of  a  hyperplasia,  but  that  coagulated  fibrin  played  a 
considerable  part  in  their  formation.  The  aortic  valves  were  altogether  in- 
sufficient. 

A  twelfth  case,  endocarditis,  is  reported  by  M.  Emile  Morel. ]  The 
patient  had  gonorrhoea  and  gonorrhoea!  rheumatism  of  the  left  sacro-iliac 
articulation,  and  then  of  the  right  tibio-tarsal,  and  of  the  metacarpo-pha- 
langeal  joints.  Fourteen  days  after  admission  slight  bellows  murmur 
with  first  sound  and  at  apex,  base  normal,  some  degree  of  rubbing  sound. 
The  latter  began  to  abate  within  a  week,  but  the  bellows  sound  became 
rougher  ;  feeling  of  oppression,  occasional  palpitations,  pain  in  drawing 
full  breath  and  nausea  followed.  The  murmur  with  first  sound  and  at  apex 
became  more  intense,  and  was  complicated  with  gradually  increasing  mur- 
mur at  base,  which  continued  to  get  worse  for  quite  a  fortnight  after,  at 
the  close  of  which  time  the  tracing  but  not  the  stethoscope  pointed  to 

1  Op.  citat. ,  p.  27. 


250  ON    GONORRHCEA. 

aortic  incompetence.  After  this  the  patient  began  to  improve,  and  in 
about  a  fortnight  left  with  the  sound  at  base  much  diminished,  that  at 
apex  almost  gone. 

The  thirteenth  case,  endocarditis,  is  by  the  same  gentleman.1  Within 
three  weeks  from  the  time  of  contracting  gonorrhoea  the  patient  had  gone 
through  double  conjunctivitis,  gonorrhoea!  rheumatism  of  right  foot  and 
knee,  left  knee  and  right  tibio-tarsal  joint ;  and  at  about  the  close  of  the 
three  weeks  was  found  to  have  rapid  sound  (bruit  de  galop),  and  hyper- 
trophy, the  apex  acting  in  the  sixth  intercostal  space;  bellows  murmur  at 
both  base  and  apex,  synchronous  with  first  sound.  Three  days  after,  tril- 
ling murmur  at  base  masking  first  and  second  sound  ;  sphygmograph 
tracings  showed  marks  of  aortic  insufficiency.  These  symptoms  gradually 
disappeared,  and  at  the  end  of  about  three  weeks  the  murmur  at  the  base 
was  gone,  and  only  a  little  mitral  insufficiency  remained.  A  fortnight 
later  the  patient  left. 

The  fourteenth  case,  also  endocarditis,  is  by  M.  Baudin.2  The  patient 
was  attacked  in  the  tenth  week  of  his  gonorrhoea  with  palpitation  and  in- 
crease in  area  of  cardiac  dulness  ;  murmur  at  base  involving  close  of  first 
sound  and  whole  of  second.  Next  day  but  one  violent  shivering,  rasping 
character  and  loudness  of  murmur  ;  a  rumbling,  fremitus,  detected*  on 
placing  hand  over  cardiac  region.  Temperature,  104°  ;  pulse,  100.  The 
patient  recovered  quickly  under  the  operation  of  digitalis  infusion,  opium, 
castor-oil,  and  blistering.  As  in  the  cases  of  Marty  and  of  Lacassague, 
there  was  no  rheumatism.  M.  Hervieux  gives 3  another  case  of  what  he 
simply  calls  gonorrhoea!  heart  affection.  One  of  endocarditis  following 
severe  gonorrhoea. and  bad  gonorrhceal  rheumatism  is  related4  by  M. 
Meuriot.  Shivering  set  in  attended  by  delirium,  a  singular  and  threaten- 
ing form  of  purpura,  and  vomiting.  After  death  the  mitral  valve  was 
found  coated  with  warty  vegetations,  particularly  at  its  free  edge  ;  there 
were  also  a  few  on  the  tricuspid  valve.  The  case  is  doubtful,  the  patient, 
a  young  man,  evidently  a  most  reckless,  dissipated  person,  having  been 
exposed  to  sufficient  inclemency  of  weather  to  set  up  ordinary  rheuma- 
tism and  endocarditis.  Dr.  Pye-Smith  found  systolic  bruit  at  base,  in  a 
man,  relieved  after  three  months'  stay  in  the  hospital.  He  thinks  it  possi- 
ble that  the  sound  was  purely  functional,  especially  as  there  were  no 
symptoms  of  organic  disease  of  heart.  Mr.  Davies-Colley  gives  5  one  of 
pericardia!  inflammation,  not  severe,  ending  in  recovery,  and  one  "  of  sys- 
tolic bruit  at  base,  only  presumably  gonorrhceal.  He  also  refers  to  two  if 
not  three  specimens,  in  Guy's  Hospital  Museum,  of  valvular  disease  asso- 
ciated with  gonorrhoea,  but  the  evidence  of  the  connection  is  again  incom- 
plete, and  I  have  therefore  only  admitted  the  first  case. 

1  Op.  citat.,  p.  29.  *  Recueil  des  Memoires  de  Medecine,  p.  530.-   1879. 

*Op.  citat.,  p.  355.  "  Gazette  des  Hopitaux,  p.  1.     1868. 

5  Op.  citat.,  p.  190.  •  Obstetrical  Journal,  p.  160.     1878-79. 


TREATMENT.  251 

Out  of  these  sixteen  cases,  then,  two  proved  fatal,  and  some  of  the  others 
were  of  a  very  threatening  nature  ;  such  symptoms,  too,  as  some  of  the 
patients  suffered  from  when  they  left  the  hospital,  prolonged  rough  state 
of  the  first  sound  and  mitral  insufficiency,  are  of  a  very  disquieting  kind. 
M  Marty,  indeed,  considers  endocarditis  set  up  in  this  way  to  be  just  as 
dangerous  as  the  idiopathic  form.  M.  Voelker's  second  case,  though  quoted 
by  Marty,  Morel,  etc.,  I  cannot  find  in  the  only  edition  of  his  essay  which 
I  have  seen.  His  eighth  "  observation  "  is  mentioned  by  some  authors  as 
containing  the  particulars  of  this  case,  but  I  see  nothing  of  the  kind,  and 
Voelker  expressly  says  there  was  nothing  wrong  with  the  heart  and  lungs. 
All  the  cases  seen  abroad  but  two,  those  recorded  by  Brandes,  occurred 
in  France  ;  all  the  patients  were  males,  and  their  ages  ranged  from  twenty- 
three  to  fifty,  so  that  time  of  life  counts  for  almost  nothing.  Except  in 
the  case  communicated  by  M.  Baudin,  it  is  very  doubtful  whether  treat- 
ment influenced  the  issue  much  more  than  mere  rest  would  have  done. 
Although  I  have  ranged  cardiac  disturbance  among  the  complications  of 
rheumatism,  the  reader  will  have  noticed  that,  in  three  of  the  cases  the 
latter  was  not  present  at  all ;  but  to  have  taken  these  as  a  separate  divi- 
sion, would  have  been  over-refining  for  the  mere  sake  of  system.  A  defect, 
similar  to  the  above  attaches  to  the  arrangement  of  pyaemia  among  the 
complications  of  gonorrhoea!  rheumatism. 

c.  Gonorrhceal  Meningitis. — Several  years  ago  I  had  under  my  care  a 
case  which  interested  me.  The  patient  had  intercourse  with  a  girl  who 
gave  him  gonorrhoea.  He  went  into  the  country  with  this  discharge  still 
on  him,  and  was  there  attacked  by  rheumatism,  which,  according  to  the 
surgeon  who  attended  him,  flew  to  the  brain,  and  of  this  he  quickly  died. 
Previous  to  this  he  had  several  times  consulted  me,  and  I  know  that  he 
never  had  gonorrhoea,  rheumatism,  or  brain  affection.  The  sequence  of 
events  led  me  to  wonder  whether  gonorrhoaal  rheumatism  had  in  this  case 
attacked  the  dura  mater,  as  it  almost  certainly  did  the  sheath  of  the  spinal 
cord  in  another  case,  but  I  could  find  nothing  which  threw  light  upon  the 
matter  till  I  came  upon  a  case  quoted  by  Tixier  from  M.  Fontan.  In  this 
the  patient,  after  his  gonorrhoea  had  lasted  three  weeks,  was  seized  with 
rather  sharp  pains  in  the  wrists  and  right  knee,  accompanied  by  redness 
and  swelling  of  the  affected  parts.  There  was  also  fever,  the  skin  was  hot, 
and  there  was  loss  of  appetite.  The  second  day  after  admission  the  right 
instep  was  assailed,  and  on  the  night  of  the  next  day  he  was  disturbed 
with  vivid  dreams,  and  got  out  of  bed  several  times  without  any  reason  ; 
in  the  morning  he  complained  much  of  his  head,  but  was  perfectly  rational. 
The  next  evening  he  was  extremely  excited  and  talked  incoherently  ;  eager 
expression  of  face,  constant  jerking  of  limbs,  restraint  necessary  to  prevent 
him  getting  out  of  bed.  Pulse  108  ;  body  bathed  in  perspiration.  The 
agitation  and  rambling  continued  the  next  day,  with  repeated  attempts  at 
swallowing,  cramp  of  upper  limbs,  and  dilatation  of  pupils.  These  symp- 


252  ON    GONORRHOEA. 

toms  soon  culminated  in  extreme  loquacity,  disturbance  of  the  intellect  to 
the  degree  of  its  being  impossible  to  extract  a  rational  answer  from  him  ; 
disordered  movements  of  the  limbs,  trembling  of  the  hands  accompanied 
by  dryness  of  the  tongue,  heat  of  the  skin,  and  profuse  fetid  perspirations. 
The  pulse  140  ;  involuntary  and  very  free  discharge  of  urine.  The  day 
after,  however,  he  began  to  improve  ;  he  had  had  a  quiet  sleep,  and  the 
pulse  had  fallen  twenty  beats.  In  the  evening  he  replied  more  coherently 
to  questions,  and  consented  to  take  food,  which  he  had  previously  refused 
to  do ;  the  pupils  had  regained  their  normal  condition.  Two  days  later  the 
pulse  had  fallen  to  80,  and  there  was  less  perspiration  ;  the  day  after  that 
he  began  to  realize  his  position.  The  patient  had  two  or  three  slight  out- 
breaks of  pain  in  the  joints,  and  once  a  threatening  of  some  return  of  the 
head  symptoms  ;  however,  thirty-two  days  after  admission  he  left  the  hos- 
pital, well  advanced  on  the  way  to  complete  recovery.  The  treatment  con- 
sisted in  the  use  of  Dover's  powder  twice  in  the  evening,  accompanied  and 
followed  by  draughts  of  nitre  and  dandelion,  quinine  with  opium  every  two 
hours,  purgative  enemata,  sinapisms  and  blisters.  M.  Moi-el  quotes  a  case 
related  by  Messrs.  Desnos  and  Lemaistre,  of  gonorrhoeal  rheumatism  com- 
plicated with  cerebral  symptoms.  A  case  of  "  troubles  cerebraux,"  from 
the  same  cause,  is  also  noted  '  as  occurring  in  M.  Kicord's  practice. 

d.  Gonorrhoeal  Myelitis. — I  have  already  mentioned  a  case  in  which  the 
rheumatic  affection  certainly  seemed  to  extend  up  the  spinal  cord,  and  M. 
Tixier  gives 2  another.     The  patient,  a  young  man  nineteen  years  old,  had 
suffered  for  ten  days  from  violent    gonorrhoeal    rheumatic  pain  in  the 
shoulders,  arms,  and  along  the  vertebral  column,  when  all  at  once,  without 
exertion,  chill  or  any  known  cause,  he  found  it  impossible  to  rise,  the  legs 
being  asleep  ;  the  day  after,  the  pain  in  the  limbs  had  disappeared,  but  he 
could  not  move  the  lower  members  at  all.     The  day  after  this,  date  of  his 
admission,  it  was  found  that  there  was  almost   complete  paraplegia,  the 
paralysis  reaching  to  the  attachments  of  the  diaphragm  ;  the  legs  were  in 
a  state   of  incomplete  anaesthesia,  but  perfect  analgesia.      The  bladder 
reached  to  the  level  of  the  umbilicus,  the  discharge  from  the  urethra  still 
continued.     A  week  after  admission  the  patient  was  cut  off  by  cholera. 
According  to  Tixier 3  M.  Eicord  also  saw  a  case  in  which  paraplegia  fol- 
lowed upon  gonorrhoea. 

e.  Gonorrhoeal  (?)  Hepatitis. — M.  Tixier  quite  believes  in  this  complica- 
tion of  gonorrhceal  rheumatism/  and  the  case  which  he  relates  in  support 
of  his  opinion  deserves  careful  consideration.     The  patient,  a  man  thirty- 
two  years  old,  who  had  twice  before  suffered  from  gonorrhoea,  and  had 
contracted  his  present  attack  four  months  previously,  had  already  been 
previously  invalided  fifteen  days  for  it  and  orchitis,  and  now  re-entered 

1  Gazette  des  Hopitaux,  p.  2.     1868.  'Op.  citat.,  p.  89. 

3  Op   citat.,  p.  64.  40p.  citat.,  p.  62. 


TREATMENT.  253 

with  a  considerable  swelling  on  each  side  of  the  scrotum,  particularly  on 
the  left,  the  skin  being  red  and  almost  erysipelatous.  He  was  feverish  and 
unwell,  and  had  just  been  attacked  with  violent  gonorrhceal  rheumatism. 
The  stomach  was  disturbed,  the  appetite  lost,  and  the  tongue  coated.  He 
had  a  jaundiced  tint  of  very  characteristic  kind  ;  the  region  of  the  liver 
was  rather  sensitive,  and  the  gland  somewhat  encroaching  upon  the  false 
ribs.  On  the  day  of  entry  he  twice  had  bilious  vomiting.  Ulceration  and 
sloughing  having  ensued  at  a  prominent  part  of  the  scrotal  swelling,  the 
patient  was  removed  to  a  surgical  ward,  the  icteric  hue  still  prevailing. 
The  lesion  of  the  scrotum  being  healed,  the  patient  left  at  the  end  of 
something  like  five  weeks  later,  the  jaundice  and  sensibility  of  the  liver 
being  then  gone.  t 

f.  Gonorrhceal  (?)   Nephritis. — M.  Hardy  mentions '  a  case  in   which 
gonorrhceal  rheumatism  was  accompanied  by  nephritis,  as  manifested  by 
albuminous  urine,  paleness,  and  anaemia. 

g.  Gonorrhceal  Pycemia. — Two  cases  of  this  kind,  ending  fatally,  are  re- 
ported *  by  Dr.  Charteris,      The  first  is  that  of  a  lad  seventeen  years  old, 
suffering  under  his  third  gonorrhoea,  accompanied  this  time  by  retention 
of  urine,  who  was  admitted  into  the  Royal  Infirmary  at  Glasgow.     Fifteen 
days  after  admission  he  was  attacked  with  shivering,  followed  by  rise  of 
temperature  and  pains  "in  all  his  bones.''    Pain  and  redness  also  came 
on  in  the  right  ankle  and  knee  ;  there  was  likewise  pain  in  the  left  shoul- 
der, which  soon  became  intense,  but  no  redness  or  swelling.     Treatment 
seems  to  have  been  quite  powerless,  the  suffering  was  not  relieved,  profuse 
sweating  set  in.  the  breath  acquired  a  hay-like  odor,  and  the  patient  died 
six  days  after  these  complications  had  begun.     At  the  autopsy,  on  opening 
the  swelling  at  the  left  shoulder,  a  quantity  of  grayish  yellow  pus  escaped. 
The  periosteum  was  found  to  be  separated  along  the  whole  length  of  the 
left  clavicle  except  at  the  extremity.     At  one  point  the  pus  had  made  its 
way  through  the  periosteum  and  diffused  itself  among  the  cellular  tissue 
of  the  neck.     The  articulation  at  each  end  of  the  clavicle  was  healthy  and 
not  opened  into.     The  right  shoulder-joint  contained  some  similar  gray 
pus.     There  seems  to  have  been  nothing  which  accounted  for  death. 

In  the  second  case  the  patient,  a  man,  was  thirty  years  old.  The  gonor- 
rhoea had  lasted  two  years,  almost  disappearing  when  the  patient  abstained 
from  stimulants,  and  returning  so  soon  as  ever  he  took  to  them  again. 
At  last,  wearied  out  with  the  persistence  of  his  complaint,  he  decided  to 
give  them  up  altogether,  and  seems  to  have  paid  the  penalty  of  his  life  for 
doing  so  ;  though  how  such  a  step  could  set  up  the  symptoms  to  be  pre- 
sently mentioned,  how  the  effect  can  in  any  way  be  connected  with  the 
cause,  is  to  me  incomprehensible.  Be  that  as  it  may,  the  patient's  health 


1  Gazette  des  Hopitaux.    p.  1185.     1877. 

2  British  Medical  Journal,  vol.  ii.,  p.  711.     1876. 


254  ON    GONORRHCEA. 

seems  to  have  quite  given  way  under  the  change  to  abstinence,  for  when 
Dr.  Charteris  was  called  to  him  he  found  him  in  a  low  state,  presenting  on 
the  left  forearm  a  well-marked  patch  of  erysipelas.  An  abscess,  which  fol- 
lowed this,  was  opened.  Two  days  after,  the  patient  complained  of  excru- 
ciating pain  in  the  left  hip-joint ;  at  the  end  of  three  weeks  fluctuation 
was  so  distinct  at  the  seat  of  pain  that  it  was  decided  to  open  the  abscess 
antiseptically,  with  the  result  of  evacuating  two  pints  of  thin,  gray  pus. 
Fever,  emaciation,  and  night  sweats  with  high  temperature  now  ap- 
peared. The  operation  was  succeeded  by  great  pain  of  a  throbbing  na- 
ture in  the  region  of  the  liver,  pointing  to  pysemic  abscess.  The  patient 
became  greatly  emaciated  and  gradually  sank.  He  was  never  delirious, 
but  during  the  last  two  days  of  life  vision  failed  so  completely  that  he  was 
unable  to  distinguish  light  from  darkness.  His  breath  had  the  same  hay- 
like  odor  as  in  the  preceding  case ;  the  pupils  were  widely  dilated.  No 
post-mortem  was  allowed. 

h.  Gonorrhceal  Adenitis,  etc. — As  another  complication  of  gonorrhoea 
and  gonorrhceal  rheumatism,  both  in  the  declining  stage,  M.  Fereol  re- 
ports '  a  case  of  swelling  of  the  gland  under  the  angle  of  the  right  jaw  of 
the  most  severe  nature,  movement  of  the  jaw  being  very  limited  and  ex- 
ploration of  the  pharynx  impossible.  The  swelling  was  opened  and  with 
the  best  effect,  although  no  pus  was  found.  Tixier  saw  two  similar  cases. 
In  one,2  after  the  discharge  had  lasted  quite  nine  or  ten  weeks,  the  patient 
was  admitted  for  quinsy  and  difficulty  in  opening  the  mouth,  with  pain  on 
moving  the  jaw.  Nearly  two  months  after,  pain  in  the  left  temporo-max- 
illary  articulation  set  in,  with  difficulty  in  depressing  the  jaw.  He  was 
then  readmitted  with  considerable  swelling  over  the  affected  part,  the  skin 
of  which  was  red  as  if  erysipelatous,  pressure  inducing  extreme  pain. 
There  was  some  little  fever,  but  all  the  symptoms  yielded  quickly  under 
the  influence  of  rest,  belladonna  ointment,  etc.  Fournier  saw  a  collection 
of  serum,  the  size  of  an  almond,  on  the  dorsal  aspect  of  the  first  metacarpal 
space  after  severe  gonorrhceal  rheumatism  of  the  wrist  in  a  man  ;  it  was 
cured  by  opening,  under  which  it  shrank  and  got  well.  Local  neuralgia 
has  also  been  noticed3  as  a  sequela  of  gonorrhceal  rheumatism,  and  M. 
Foumier  quotes,  as  issuing  from  the  same  source,  instances  of  muscular 
pains,  lumbago,  wry-neck,  temporary  diplopia,  and  partial  deafness.  The 
catalogue  of  results  is,  therefore,  evidently  enough,  of  startling  dimensions, 
and  gonorrhoea  perhaps  makes  a  wider  and  deeper  impression  on  the  sys- 
tem than  has  been  usually  thought.  At  the  same  time  I  have  to  add  that 
most  of  these  after-effects  are  quite  unknown  to  myself,  and  the  others  ex- 
cessively rare.  To  these  may  be  added,  for  mere  convenience  sake,  certain 
anomalous  disturbances  and  sensations  left  behind  by  gonorrhoea,  irrespec- 
tive of  rheumatism.  Among  these  are  enumerated  itching,  tickling,  and 

1  Archives  Generates  de  Medecine,  tome  ii.,  p.  208.     1866. 
5  Op.  citat.,  p.  61.  3  Tixier:  Op.  citat.,  p.  64. 


TREATMENT.  255 

sense  of  crawliiig  in  the  urethra  ;  tenderness  on  erection  and  making  water, 
all  remediable  enough ;  frequent  desire  to  make  water,  which  may  last  for 
life  ;  rolling  of  the  testicles,  mentioned,  I  believe,  only  by  Lagneau  and 
unknown  to  me  ;  loss  of  proper  sensation  on  emission  spoken  of  by  Cas- 
telnau. 

We  have  now  to  examine  the  machinery  by  means  of  which  this  obsti- 
nate complaint  is  called  into  activity.  Mr.  Erichsen,  who  divides '  the 
complaint  into  the  fibroid  or  plastic  and  the  suppurative,  thinks  the  former 
"is  intimately  associated  with  those  forms  of  blood  disease  in  which  fibrin- 
ous  exudations  are  formed  in  internal  organs,  more  especially  on  the 
serous  surfaces ; "  but  I  never  yet  could  make  out  that  there  is  anything 
which  can  properly  be  called  blood  disease  in  either  case.  Mr.  Bond  con- 
siders 2  that  it  is  due  to  absorption  of  a  morbid  material  from  the  urethra, 
though  he  is  "  not  prepared  to  explain  "  the  exact  way  in  which  this  pro- 
cess takes  place.  According  to.  him,  rheumatism  so  essentially  depends 
upon  the  disease  of  the  urethra,  that  the  first  condition  of  successful  treat- 
ment is  to  set  this  canal  in  good  order  ;  an  excellent  rule  of  practice,  but 
subject  to  exceptions,  for  the  rheumatism  has  been  successfully  combated  3 
while  the  discharge  was  not  treated  at  all,  and  relapsed  after  the  rheuma- 
tism was  cured.  He  finds  the  complaint  often  accompanied  by  congestion 
of  the  sclerotic,  whereas  Dr.  Pye-Smith  never  saw  this  (sclerotitis)  in  rheu- 
matic fever,  gout,  or  typical  osteo-arthritis.  Mr.  Bond  also  says  it  is  most 
prevalent  among  the  poor,  ill-fed  and  anaemic,  most  likely  because  such 
states  predominate  in  dispensary  practice,  of  which  he  is  speaking ;  in  pri- 
vate practice  I  have  seen  gonorrhoea!  rheumatism  often  enough  among  men 
both  robust  and  well-fed. 

With  regard  to  any  such  conjectures,  as  that  the  complaint  is  due  to 
metastasis  of  the  gonorrhoea  or  its  suppression  by  means  of  copaiba  and 
injection,  there  is  a  short  answer.  The  complaint  occurs  when  no  specifics 
have  been  given  and  no  injections  used.  I  have  attended  cases  where  the 
pain  has  come  on  within  seventy-two,  and  even  forty-eight,  hours  after  the 
appearance  of  the  discharge,  and  have  even  known  patients  uncertain  as  to 
which  began  first.  The  discharge  is  not  unusually,  if  it  be  ever,  suppressed 
by  the  outbreak  of  the  rheumatism,  but  indeed  there  is  no  such  thing  as 
thorough  suppression  of  the  gonorrhoea  in  the  usual  sense  of  the  word ; 
for  what  effects  such  a  change  cures  the  running,  and  very  often  the  rheu- 
matism cannot  be  subdued  till  the  purulent  secretion  is  got  under.  M. 
Voelker  brings 4  evidence  to  show  that  the  rheumatism  may  spring  up, 
run  its  course  and  disappear,  without  the  gonorrhoea  being  in  the  least 
affected ;  and  Fournier  has  never  seen  the  discharge  suspended.  B 

1  Science  and  Art  of  Surgery,  vol.  ii.,  p.  883.     1877. 

5  Lancet,  vol.  i  ,  p.  396.     1872.  s  Ibid.,  vol.  ii.,  p.  265.     1860. 

4  Op.  citat.,  p.  50.  6  Nouveau  Dictionnaire,  tome  v.,  p.  229. 


256  ON    GONOKRHCEA. 

M.  Hardy  says '  it  seems  that  when  the  gonorrhoea  stops  there  is  "  une 
veritable"  metastase,  comme  un  transport  des  naateriaux  morbifiques  d'un 
endroit  u  1'autre."  This  is  another  specimen  of  that  vagueness  which  has 
ever  been  the  bane  of  medicine.  Morbid  materials  may  mean  almost  any- 
thing, and  the  first  omission  in  this  paragraph  is  that  they  are  not  dis- 
tinctly specified.  I  will  take  the  liberty  of  restricting  the  term  to  sub- 
stances really  known  to  exist.  These  are  the  pus  secreted  on  the  surface 
of  the  urethra,  and  the  products  of  inflammation  in  the  walls  of  this  canal 
and  the  surrounding  cellular  tissue,  such  products  being  ill-conditioned 
lymph,  effused  serum,  wandering  cells  and  pus  cells  ;  and  I  should  be  glad 
if  we  are  to  understand  that  these  are  transported  to  the  knee  or  ankle, 
such  frequent  sites  of  gonorrhoea!  rheumatism ;  or  if  we  should  adopt  M. 
Castelnau's  suggestion  2  as  to  metastasis  in  orchitis,  that  it  is  the  principle 
which  is  translated,  and  that  this  begins  operations  by  infecting  the  whole 
organism.  I  should  also  be  glad  to  know  how  the  rheumatism  is  set  up 
when  there  is  no  arrest  of  the  discharge,  and  consequently  no  metastasis  ; 
though  indeed  the  employment  of  the  term  here  is  an  entire  mistake. 
Metastasis  means  properly  the  cessation  of  a  disease  in  one  part  and  its 
outbreak  in  another  ;  M.  Hardy  employs  it  to  signify  the  conversion  of  a 
disease,  during  its  passage,  from  a  suppurative  to  a  non-suppurative  form. 

M.  Guerin  feels  inclined  to  believe  that  gonorrhoea!  rheumatism  and 
ophthalmia  are  specially  to  be  feared  when  the  discharge  is  preceded  by 
incubation  ;  and  Tixier  thinks 3  that  not  only  the  beginning  but  the  course 
of  the  disease  is  different,  there  being  usually  less  pain  in  the  urethra  when 
rheumatism  follows ;  and  he  expresses 4  the  greatest  astonishment  at  M. 
Eollet  saying  that  the  most  general  sign  of  gonorrhceal  rheumatism  coming 
on  is  abundance  of  discharge.  According  to  M.  Fourestie,  Fereol  noticed 
it  in  eight  cases  where  the  discharge  was  very  mild.  M.  Fourestie  himself 
maintains  &  that  when  it  attacks  a  patient  suffering  from  an  old  gonorrhoea, 
it  runs  in  many  respects  a  different  course,  there  being  no  acute  arthritis, 
no  rheumatic  fluxion  generalizing  itself.  The  attack  wears  all  the  charac- 
ters of  a  chronic  case,  tends  particularly  to  the  synovial  capsules,  and  is 
accompanied  by  pastiness  and  severe  pain  on  pressure  ;  symptoms  not  re- 
sembling those  which  accompany  acute  or  subacute  gonorrhoeal  rheumatism. 
I  have  failed  to  identify  it  with  any  particular  form  of  gonorrhoea. 

Some  of  the  French  medical  men  seem  to  be  much  interested  in  the 
question,  of  whether  gonorrhoea  here  sets  up  a  new  diathesis  or  evokes  a 
latent  one,  and  draw  a  distinction  between  a  diathesis  and  a  predisposition. 
I  must  dissent  unequivocally  from  the  first  proposition.  I  have  examined 
hundreds  of  patients  after  gonorrhoea,  and  in  no  instance  have  I  seen  rea- 
son to  believe  that  it  affected  the  constitution  in  such  a  way  as  "  acquiring 

1  Gazette  des  Hopitaux,  p.  1186.     1877.  *  Op.  citat.,  p.  202. 

3  Op.  citat.,  p.  20.  4  Ibid.,  p.  31. 

6  Gazette  Mcdicale,  pp.  342,  409.     1875. 


TKEATMENT.  257 

a  diathesis  "  would  infer  ;  while  there  is  fair  reason  for  suspecting  that  it 
awakens  a  predisposition,  because  by  no  effort,  no  precaution,  can  either 
patient  or  surgeon  avert  the  attack  of  rheumatism  when  once  the  gonor- 
rhoea has  begun.  I  do  not  see,  too,  how  a  diathesis  can  be  acquired  within 
seventy-two  hours,  and  as  to  the  distinction  between  this  and  predisposi- 
tion, it  seems  to  me  that  in  the  disease  they  mean  much  the  same  thing. 

All  that  I  can  make  out  may  be  summed  up  in  the  following  conclu- 
sions. Gonorrhoea  rather  rarely  implicates  the  structures  of  animal  life, 
and  then  chiefly  the  fibrous  and  serous  tissues ;  the  proportion  in  which 
the  disturbance  extends  to  these  has  not  yet  been  satisfactorily  determined. 
I  only  noticed  such  complications  about  once  in  every  twenty-three  cases, 
being  in  excess  of  that  observed  by  M.  Fournier ;  but  whatever  the  ratio 
may  be,  I  believe  it  to  be  entirely  due  to  the  occurrence,  in  a  certain  pro- 
portion of  the  population,  of  gonorrhoeal  rheumatic,  not  rheumatic,  diathesis, 
which  I  must,  all  arguments  to  the  contrary,  look  upon  as  two  different 
things.  I  entirely  dissent  from  the  view  expressed  by  M.  Quinquaud  1  and 
M.  Mauriac,2  that  the  gonorrhoea,  in  some  instances  at  least,  intensifies  or 
localizes  a  rheumatic  disposition,  having  never  seen  an  instance  of  such  a 
process. 

Prognosis. — Judging  by  my  own  cases,  I  should  say  that  nearly  every 
case  of  gonorrhoeal  rheumatism  gets  thoroughly  well  in  time  ;  in  every  in- 
stance where  I  have  had  an  opportunity  of  examining  the  patient,  the  cure 
has  been  complete.  But  only  too  frequently  I  have  had  no  such  opportu- 
nity, having  entirely  lost  sight  of  the  patients,  and  some  have  given  up 
treatment  in  disgust ;  while  I  certainly  should  not  expect  recoveiy  in  such 
a  case  as  that  mentioned  at  page  246,  where  symptoms  of  paralysis  were 
setting  in  when  the  patient  was  last  seen.  M.  Gosselin  takes  3  a  most 
unfavorable  view  of  the  matter.  He  says  anchylosis  is  to  be  expected,  be- 
cause the  natural  tendency  in  this  kind  of  rheumatism  is  toward  destruc- 
tion of  the  diarthrodial  cartilages,  which  is  necessarily  followed  by  anchy- 
losis, this  being  in  consequence  the  most  frequent  termination  in  all  cases 
of  blennorrhagic  arthritis.  Erichsen  is  much  of  the  same  opinion.  Da- 
vies-Colley  thinks  that  in  some  cases  there  is  plentiful  development  of 
fibrous  adhesions,  and  that  the  cartilages  are  eroded.  Duplay  and  Brun 
consider  that  the  rapid  disorganization  of  the  principal  elements  of  the 
joint  attacked,  the  elbow  far  most  frequently,  is  one  of  the  most  marked 
characteristics  of  acute  gonorrhoeal  arthritis.  It  has  often  been  found 
necessary  to  break  up  adhesion  of  the  elbow,  and  even  the  hip-joint,4  aris- 
ing from  this  complaint.  M.  Hardy,  on  the  other  hand,  considers 6  that 
cure  is  the  rule,  hydrarthrosis  and  anchylosis  being  less  frequent.  M. 

1  Gazette  des  Hopitaux,  pp.  731,  732.     1875. 

J  Ibid.,  p.  297.  3  Ibid.,  p.  1043.     1880. 

4 Ibid.,  p.  121.     1879.  6  Ibid.,  p.  1186.     1877. 
17 


258  ON    GONORRHXEA. 

Maymou,  too,  looks  upon  the  prognosis  as  hopeful,  though  the  cure  may 
be  slow. 

Among  the  patients  at  the  old  Dreadnought  Hospital  gonorrhoea!  rheu- 
matism was  often  seen  to  assume  a  degenerative  form,  marked  by  struct- 
ural changes  in  the  ligaments,  cartilages,  and  bones,  and  "peripheric,  or 
interstitial,  or  fibrous  anchylosis,"  occasionally  following. 

Treatment  usually  adopted. — The  older  method,  as  it  might  be  called, 
of  meeting  this  complaint  was  rather  a  failure.  The  usual  run  of  reme- 
dies for  rheumatism,  including  colchicum,  iodide  of  potassium,  alkalies, 
guaiacum  and  antimony,  only  too  often  exerted  little  or  no  influence  over 
the  obdurate  disorder,  and  the  patient  was  drenched  with  medicines,  week 
after  week,  without  obtaining  any  more  relief  than  he  would  have  derived 
from  rest  in  bed.  I  believe  now  that  the  only  good  I  did  my  patients, 
when  employing  this  method,  was  by  means  of  the  sedatives  which  I  gave 
them  without  stint.  The  more  modern  system,  that  with  salicylates,  seems 
to  have  been  equally  a  failure.  For  instance,  Dr.  Herman  Weber  reports  ' 
a  very  unsatisfactory  experience  with  "  salicin  and  its  congeners  "  in  this 
affection.  One  patient  was  sick  after  every  dose  of  salicin,  salicylic  acid, 
or  salicylate  of  soda.  One  took,  for  two  days,  fifteen  grains  of  salicin 
every  two  hours,  and  then  for  three  days  twenty  grains  of  salicylate  of 
soda  every  two  hours,  without  obtaining  more  benefit  than  rest  usually  ef- 
fects in  such  a  lapse  of  time  ;  it  then  became  necessary  to  discontinue 
the  remedy  on  account  of  nausea  and  giddiness.  In  a  third  case  the  pain 
and  swelling  in  the  joints  and  the  pyrexia  were  much  relieved  after  two 
days  of  this  treatment,  while  the  swelling  of  the  joints  and  the  state  of  the 
urethra  wrere  not  materially  influenced,  there  being  here  evidently  a  slight 
error  in  the  report.  In  the  fourth  case,  after  three  days'  use  of  the  sali- 
cylate of  soda,  twenty  grains  every  two  hours,  the  pyrexia,  pain,  and  swelling 
were  much  reduced,  the  state  of  the  urethra  remaining  almost  unchanged. 
Dr.  Weber's  unfavorable  experience  is  quite  confirmed  by  that  of  M.  Des- 
nos,2  as  also  by  a  case  from  the  practice  of  M.  Hardy,3  the  patient  taking 
six  grammes  daily  of  the  salicylate  of  soda,  with  no  other  result  than  the 
slight  amelioration  which  rest  alone  would  have  induced.  Brun  mentions 
a  case  in  the  practice  of  M.  Fernet,  where  the  dose  of  salicylate  of  soda 
was  carried  to  four  grammes  without  any  effect. 

Proposed  Plan  of  Treatment. — With  the  exception  of  the  sedatives,  an 
occasional  dose  of  calomel  and  black  draught,  and  blistering,  in  all  of 
which  I  confess  to  great  faith,  I  have  long  abandoned  every  item  of  the 
old  treatment  in  favor  of  quinine,  and  as  to  the  salicylates,  I  am  quite 
satisfied  with  the  trials  which  others  have  made.  M.  Maymou  considers 
that  quinine  has  failed.  He  does  not  state  in  what  form  or  in  what  doses 
it  was  given,  but  in  solution  with  sulphate  of  magnesia,  and  freely  em- 

1  British  Medical  Journal,  vol.  i.,  p.  108.     1877. 

'Gazette  des  Hupitaux,  p.  1067.     1877.        -Ibid.,  p.  1185. 


TREATMENT.  259 

ployed,  I  Lave  found  it  most  useful.  It  seems  to  act  much  more  de- 
cidedly on  the  complaint,  and  to  suit  the  system  better,  when  the  calomel 
purge  and  black  draught  are  taken  along  with  it ;  in  addition  to  which  I 
never  hesitate  to  recommend  blistering  and  sedatives,  of  which  large  doses 
of  liquor  opii  and  tinctura  opii  seem  to  me  to  be  much  the  best. 

Early  in  February,  1874,  I  was  consulted  by  a  surgeon  about  a  patient 
suffering  from  most  obstinate  gonorrhceal  rheumatism  in  the  ankle,  knee, 
and  back,  which  ankle  and  knee  was  not  stated.  The  patient  had  first 
noticed  the  discharge  about  a  week  before  he  applied  to  the  surgeon,  and 
the  rheumatism  showed  itself  a  few  days  after  this.  As  he  resided  at  a  long 
distance  I  had  no  opportunity  of  verifying  the  dates,  and  at  a  later  period, 
when  I  saw  the  patient,  I  omitted  to  do  so.  The  running  was  reported  to 
be  most  profuse,  and  accompanied  by  great  soreness  inside  the  urethra. 
It  had  remained  quite  unaffected  by  antiphlogistic  treatment,  potass,  copaiba, 
and  cubebs,  singly  and  combined  ;  nor  did  these  remedies  influence  the 
rheumatism,  the  pain  of  which  was  so  great  that  the  patient  had  to  take 
hydrate  of  chloral  for  weeks  to  get  some  sleep.  The  treatment  of  gonor- 
rhoea laid  down  in  this  work  was  next  tried  ;  but  with  no  better  success. 
I  recommended  that  the  rheumatism  should  be  combated  as  mentioned  in 
the  foregoing  pages. 

On  the  22d  of  May  I  was  called  to  see  the  patient,  who  had  arrived  in 
London.  The  discharge  was  so  profuse  as  to  drip  from  the  penis  when  the 
wrappings  were  taken  off.  The  rheumatism,  described  by  the  patient  as 
being  chiefly  situated  in  the  feet,  which  were  greatly  lamed  by  it,  and  also 
to  some  extent  in  the  back,  had  yielded  but  very  little,  except  in  this  respect, 
that,  whereas  it  had  formerly  fixed  itself  also  in  the  left  knee  and  hip,  and 
in  the  right  shoulder,  it  was  now  restricted  almost  entirely  to  the  parts  men- 
tioned. The  patient  was  also  suffering  from  ophthalmia  with  great  sensi- 
tiveness to  light.  He  now  mentioned  to  me  what  I  was  not  aware  of  before, 
that  he  had  thirteen  years  previously  had  an  obstinate  gonorrhoea,  which 
had  resulted  in  stricture.  This  had  been  dilated,  and  up  to  the  time  of  the 
second  infection  he  had,  at  intervals,  passed  a  pretty  large  bougie,  hi  accord- 
ance with  the  directions  given  by  the  surgeon.  He  was  thin  and  pale,  very 
dejected  in  spirits,  and  suffering  from  indigestion,  which  he  ascribed  prin- 
cipally to  the  use  of  specifics  ;  also  from  great  irritability  of  the  bladder. 
The  pain  from  the  rheumatism  was  so  severe  at  night  that  he  could  not 
sleep  without  a  sedative,  and  his  appetite  for  natural  food,  never  very  strong, 
had  quite  left  him.  In  the  interval  between  the  first  and  second  consulta- 
tions galvanism  had  been  tried  for  the  rheumatic  pain,  but  a  pretty  long 
use  of  it  had  failed  to  do  anjrgood.  On  examining  the  urethra  I  found  it 
very  much  contracted.  The  patient's  age,  I  may  remark,  was  about  thirty- 
four. 

I  ordered  this  gentleman  to  drink  a  bottle  of  burgundy  a  day,  and,  if 
he  could  not  manage  that  amount,  to  take  as  much  as  he  could,  to  have  a 


260  ON    GOISTOKRHCEA. 

large  glass  of  good  milk  and  the  best  rum  every  night  on  going  to  bed  ; 
a  restorative  diet,  comprising  plenty  of  fat  ham  and  bacon,  beef-tea  with 
vermicelli  or  isinglass  ;  to  have  quinine  at  first  twice,  and  then  three  times 
a  day,  raising  the  dose  as  fast  as  he  could  possibly  bear  it  up  to  three,  four, 
or  even  five  grains ;  to  keep  the  bowels  gently  opened  by  means  of  an  aperi- 
ent pill  containing  colchicum,  and,  when  a  sedative  was  required,  to  take 
a  full  dose  of  bimeconate  of  morphia.  For  the  rheumatism  he  was  ordered 
to  have  a  sulphur  fume  bath  occasionally,  and  after  that  a  vapor  bath. 
During  the  next  seventeen  days  the  nitrate  of  silver  was  applied  fifteen 
times,  but  very  gently  each  time,  to  the  stricture.  At  the  end  of  this  the 
patient  left  for  the  country,  feeling,  he  said,  very  much  better  and  stronger. 
The  discharge  had  diminished,  but  not  materially.  The  ophthalmia  was  a 
little  improved,  and  for  it  his  medical  attendant  was  asked  to  drop  occasion- 
ally into  each  eye  a  minim  of  solution  of  nitrate  of  silver.  He  was  directed 
to  blister  the  penis  and  perineum  well,  and  occasionally  to  pass  a  bougie. 

On  the  22d  of  July  the  patient  called  to  report  that  he  was  now  com- 
paratively a  new  man.  The  "  discharge  proper  "  of  the  gonorrhoea,  as  he 
called  it,  had  quite  ceased.  The  rheumatism,  which  had  so  completely  de- 
fied what  seemed  appropriate  means,  had  yielded  to  this  strange  treatment 
as  his  medical  attendant  seemed  to  consider  it,  and  was  dying  out.  He 
was  free  from  any  irritability  of  the  bladder.  He  could  eat  and  sleep  bet- 
ter, and  felt  much  stronger.  The  ophthalmia  seemed  slowly  passing  away. 
Beyond  the  occasional  passing  of  a  number  ten  bougie,  which  he  could  do 
very  well,  no  other  treatment  than  that  mentioned  had  been  adopted.  He 
had  continued  the  quinine,  diet,  and  vapour  baths  ;  the  sedative  almost  en- 
tirely given  up. 

Taking  all  things  into  consideration  I  thought  any  change  would  be 
injudicious,  and  therefore  simply  directed  that  the  nitrate  should  be  oc- 
casionally and  very  gently  used,  limiting  the  application  to  the  seat  of  the 
stricture  ;  that  he  should  continue  his  wine,  and,  unless  already  sick  of  it, 
the  rum  and  milk  ;  that  the  quinine  and  colchicum  should  be  resorted  to 
occasionally,  and  that  he  should  blister  once  more  at  any  rate.  I  saw  him 
again  in  the  succeeding  February,  when  he  reported  a  decided  amendment 
in  every  respect,  the  last  vestiges  of  all  except  the  stricture  having  now 
gone.  This  gentleman's  case  might  well  be  described  as  truly  deplorable  ; 
it  had  gone  on  above  eight  months  without  any  improvement  whatever, 
and  yet  the  patient,  who  ought  to  know  better  than  any  one  else,  stated 
that  he  began  to  mend  directly  the  treatment  was  changed,  and  that  the 
improvement  went  on  to  the  close  without  any  halt  or  check ;  results  which 
did  not  seem  in  any  way  likely  to  flow  from  me  measures  which  I  formerly 
suggested.  His  medical  attendant  seemed  of  quite  the  same  way  of  think- 
ing. The  patient  subsequently  had  another  attack  of  gonorrhoea  without 
rheumatism. 

"When  the  next  case  presented  itself  I  resolved  to  trust  entirely  to  the 


TREATMENT.  261 

quinine,  merely  supplementing  it  occasionally  with  an  aperient,  the  more 
so  as  the  patient  had  the  strongest  objection  to  blistering,  and  was  rather 
refractory  about  taking  sedatives,  though  he  made  no  demur  about  what  I 
should  have  thought  was  quite  as  disagreeable  a  remedy,  that  is  to  say  the 
calomel  purge  and  black  draught.  The  quinine  was  accordingly  begun  in 
grain  doses  three  times  a  day,  and  rapidly  raised  to  four  and  then  five 
grains,  and  answered  exceedingly  well.  I  had  to  interrupt  it  twice  for  a 
day  or  two  on  account  of  nausea,  headache,  indigestion,  and  diarrhoea,  evi- 
dently due  to  the  large  doses  of  copaiba  he  had  taken  ;  otherwise  the 
quinine  was  continued  uninterruptedly.  The  patient  made  a  good  recov- 
ery, the  case  being,  however,  never  very  severe ;  pain  chiefly  in  left  shoulder- 
joint. 

The  next  case  was  of  a  most  severe  character,  the  patient  being  straight- 
way laid  up  with  the  pain  which  assailed  both  ankles  and  the  right  knee, 
obtaining  its  acme  in  this  joint.  I  began  at  once  with  quinine,  and  carried 
the  dose  up  without  delay  to  six  grains  three  times  daily,  using  no  seda- 
tives, and  ordering  a  calomel  pill  and  senna  draught  only  occasionally.  The 
patient  soon  began  to  improve,  and  the  recovery  proceeded  steadily,  and 
at  a  rate  which  was  certainly  a  great  advance  upon  the  old  system.  Both 
these  patients  were  ordered  a  light  warm  diet,  plenty  of  claret,  carlowitz 
or  burgundy  as  taste  might  direct,  fortified  by  a  glass  of  old  port  every 
day,  and  a  glass  of  spirit  and  water  or  rum  and  milk  at  bedtime.  Both 
recovered  perfectly.  Since  that  time  I  have  treated  in  the  same  way,  but 
using  at  the  same  time  sedatives  rather  freely,  every  case  which  came  under 
my  care,  though  for  some  reason  or  other  I  have  not  seen  so  much  of 
gonorrhoeal  rheumatism  during  the  last  five  or  six  years.  The  results,  how- 
ever, of  the  cases  which  I  have  had,  gave  me  every  reason  to  believe  that 
such  remedies  as  hypodermic  injections,  galvanism,  painting  with  iodine, 
drawing  off  the  fluid,  needle  aspiration,  kneading,  vesication  with  nitrate 
of  silver,  belladonna  pomade,  laudanum  poultices,  sulphur  fume  baths, 
and  mineral  waters  may  one  and  all  be  dispensed  with.  At  the  same  time 
it  must  be  admitted  that  good  cures,  even  in  long-standing  cases,  have  fol- 
lowed from  drawing  off  the  fluid  from  a  knee  thus  affected  and  strapping 
the  joint  with  mercurial  plaster.1 

From  Voelker 2  we  learn  that  puncture  has  rendered  amputation  neces- 
sary, but  I  should  think  that  with  proper  precautions  no  such  result  need 
be  feared.  Demarquay,  in  cases  marked  by  great  pain,  gave  aconite  and 
opium  with  excellent  effect.  He  also  employed  immobility,  as  did  Voelker, 
Bouilly,  and  Tixier,  with  exceptionally  good  results,  the  pain  especially 
ceasing  very  quickly ;  but  Brun  gives  a  case  where  the  apparatus  could  not 
be  removed  till  the  fifty-fourth  day.  Mr.  Furneaux  Jordan  says  3  that 

1  Medical  Times,  vol.  i.,  p.  365.     1868.  'Op.  citat.,  p.  109. 

1  British  MedicalJourual,  vol.  ii.,  p.  202.     1868. 


202  ON    GONORKIKEA. 

painting  with  nitrate  of  silver,  carried  almost  to  vesication,  has  removed 
gonorrhoeal  rheumatism  of  the  knee  in  twenty-four  hours.  Mr.  Davies- 
Colley  found  warm  anodyne  lotions  relieve  the  pain. 

19.  GOXORRHCEAL  AFFECTIONS  OF  THE  EYE. — a.  Ophthalmia.  Pathology. — 
Kesembles  ordinary  purulent  ophthalmia,  except  in  its  origin,  which  is  due 
to  the  contact  of  gonorrhoeal  matter,  numerous  cases,  showing  this  to  be 
its  source,  being  detailed  by  Lawrence  '  and  others.  According  to  Founder 
contagion  can  only  explain  its  occurrence  ;  in  84  cases  Flourent  Cunier 
traced  it  to  this  origin  in  47.  It  is  more  frequent  in  the  right  eye  than 
in  the  left,  four  times  out  of  five  according  to  one  observer,  Penanguer  ;  and 
Fournier  points  out  that  it  is  the  right  hand  which  is  so  much  the  most 
frequently  carried  to  the  eye.  Only  seen,  in  the  experience  of  some  ob- 
servers, along  with  urethral  gonorrhoea,  which  explains  its  rarity  in  the 
female.  Rarely  observed  in  conjunction  with  gonorrhceal  rheumatism. 
The  conjunctiva  is  first  affected,  and  thence,  if  unchecked,  the  inflamma- 
tion extends  to  the  other  tissues.  It  is  a  very  destructive  form  of  disorder, 
but  perhaps  not  more  so  than  uncomplicated  purulent  ophthalmia.  Con- 
sidering the  prevalence  of  gonorrhoea,  it  is  a  rare  disease.  As  to  its  origin 
from  the  contact  of  purulent  matter,  I  have  only  one  observation  to  make, 
which  is,  that  I  believe  in  far  the  greater  number  of  cases  the  pus  never 
comes  into  contact  with  the  ocular  conjunctiva  at  all ;  indeed,  though  a 
few  well-authenticated  instances  have  occurred  where  pus  was  launched 
right  into  the  eye,  yet  this  accident  must  for  obvious  reasons  happen  but- 
very  rarely ;  and  the  probability  is,  that  if  the  application  of  matter  be 
the  cause,  it  acts  first  upon  the  lids  on  which  it  is  accidentally  smeared, 
much  as  I  believe  in  gonorrhoea  the  irritating  vaginal  or  urethral  pus  is 
really  only  applied  to  the  mouth  of  the  urethra. 

As  to  any  gonorrhoeal  affection  of  the  eye  arising  from  repulsion, 
considering  how  often  this  idea  has  been  refuted,  it  may  now  be  assumed 
that  it  is  sheer  waste  of  time  to  argue  with  persons  who  make  use  of  it ;  as 
well  dispute  with  a  man  who  denied  the  circulation  of  the  blood,  or 
that  the  earth  moves  round  the  sun.  But  the  very  act  of  running  counter 
to  ah1  common  sense  and  experience  has  a  charm  for  some  minds,  and 
moreover  these  men  are  wise  in  their  generation.  They  use  a  figure  of 
speech  patients  can  understand,  or  at  any  rate  fancy  they  can  understand, 
which  serves  the  purpose  just  as  well,  and  they  save  themselves  the  trouble 
of  thinking.  They  begin  with  assertions  which,  having  no  other  value,  are 
clearly  expected  to  derive  weight  enough  from  the  fact  of  their  being 
patronized  by  the  speaker  or  author  in  question,  and  these  assertions  are 
supported  by  arguments  which  only  need  looking  at  to  be  condemned  as 
faulty.  Even  were  such  a  thing  as  repulsion  conceivable,  supposing  any 
man  able  to  realize  Cullerier's  theory  that  gonorrhoeal  matter  is  transported 

1  On  Venereal  Diseases  of  the  Eye,  p.  31.    1830. 


TREATMENT.  263 

bodily  to  the  articulations,  it  could  in  no  way  explain  those  cases  where 
the  discharge  is  not  checked,  and  where  consequently  there  can  be  no  re- 
pulsion. Yet  these  are  so  much  more  numerous  that  Sir  William  Lawrence, 
who  necessarily  treated  so  many  venereal  and  eye  affections,  never  saw  a 
case  of  gonorrhceal  ophthalmia  where  arrest  of  the  discharge  took  place. ' 
M.  Tixier  makes "  a  precisely  similar  statement.  Nor  is  this  any  obsolete 
error  which  I  am  pursuing.  The  reader  has  just  seen  that,  in  reference 
to  gonorrhceal  rheumatism,  the  doctrine  of  metastasis  is  by  no  means  given 
up  ;  and  whether  the  disease  is  driven  from  the  urethra  to  a  joint,  or  at- 
tracted to  the  eye  from  the  canal,  the  process  of  translation  must  be  the 
same. 

Prognosis. — Always  serious,  the  issue  being  too  often  unfortunate,  es- 
pecially, it  has  appeared  to  me,  in  the  case  of  young  persons  of  loose  make 
and  puffy,  relaxed  tissues  ;  also  among  Irish  patients  of  the  lower  class 
resident  in  London.  When  the  patient  is  otherwise  healthy,  temperate,  and 
attentive,  there  is  a  fair  chance  of  his  doing  weh1,  but  the" best  treatment 
is  constantly  marred  by  indiscretion  and  apathy.  In  one  case  I  found,  at 
the  very  first  visit,  that  the  sight  of  both  eyes  was  almost  entirely  des- 
troyed, the  patient  having  never  applied  for  any  advice. 

Treatment  usually  adopted. — I  do  not  see  how  it  is  possible,  by  any  pro- 
cess of  mental  alchemy,  to  extract  from  the  jarring  opinions  of  those  who 
ought  to  know  best  how  to  manage  this  disease,  a  single  axiom  of  treat- 
ment which  can  be  said  to  meet  with  general  concurrence  ;  and  he  who 
can  explain,  by  any  known  system  of  pathology,  how  it  happens  that  a 
specific  affection,  of  definite  course,  is  treated  with  equal  success  by  means 
which  weaken  and  by  means  which  strengthen  the  circulation  ;  by  reme- 
dies which  increase,  and  by  remedies  which  lessen  the  cohesion  of  the 
blood ;  by  quinine  and  antiphlogistic  measures  ;  by  warm  applications, 
and  by  ice,  is  gifted  by  far  greater  powers  of  analysis  and  induction  than 
I  possess.  I  therefore  abandon  the  task  as  hopeless,  and  restrict  myself 
to  giving,  in  as  condensed  a  form  as  I  can,  an  analysis  of  the  latest  pre- 
cepts of  treatment  laid  down  by  some  of  our  most  eminent  teachers. 

Mr.  Lawson's  consists  of  tonics,3  one  item  being  quinine  in  two-grain 
doses  every  four  hours,  diffusible  stimuli  and  liberal  diet.  If  there  be 
great  pain  or  irritability,  he  gives  opium  at  bedtime,  and  when  there  is 
much  heat  of  the  skin,  thirst  and  furring  of  the  tongue,  ammonia  in  an  effer- 
vescing form.  His  local  applications  are  nitrate  of  silver  solution,  ten  to 
thirty  grains  to  an  ounce  of  distilled  water,  dropped  in  once  or  twice  a  day, 
and  a  solution  of  six  grains  of  alum,  or  one  grain  of  sulphate  of  zinc  and 
three  of  alum,  in  an  ounce  of  water,  to  wash  away  the  discharge.  A  fold  of 
linen,  wetted  with  iced  water,  is  laid  upon  the  eyelid  and  changed  every 

1  On  Venereal  Diseases  of  the  Eye,  p.  33.     1830.          *Op.  citat.,  p.  51. 
3  Practitioner,  vol.  i. ,  p.  342. 


264  ON    GONOKRHCEA. 

time  it  gets  dry.  But  as  early  as  1859  Mr.  Hancock  treated  the  disease 
with  these  doses  of  quinine.  In  the  Lancet  for  that  year  1  two  cases  are 
reported  under  his  care,  one  in  which  a  similar  dose  was  given  every  four 
hours,  conjoined  at  first  with  opium,  this  being  subsequently  withdraAvn, 
as  it  did  not  seem  to  agree  ;  and  another  where  the  same  quantity  was 
ordered  three  times  a  day,  accompanied  by  a  full  diet,  the  result  being 
highly  gratifying  in  both  cases. 

It  is  therefore  calculated  to  excite  no  little  surprise,  when  we  find  the 
disease  treated  quite  as  successfully  by  Mr.  Adams  2  with  means  so  dia- 
metrically opposed  as  bleeding,  leeches,  calomel,  and  opium  ;  and  "  almost 
invariably  cut  short "  by  Mr.  Collis  3  in  "  twenty-four  hours  "  with  a  half 
grain  solution  of  nitrate  of  silver,  used  very  frequently,  to  the  entire  ex- 
clusion of  all  medicines.  As  to  the  bleeding  recommended  by  Mr.  Adams, 
it  seems  but  another  word  for  almost  certain  mischief  ;  the  only  inference 
to  be  drawn  from  the  horrors  recorded  by  Wardrop,  Lawrence,  and  others, 
is  that  at  least  half  the  victims  to  the  destructive  influence  of  antiphlogistic 
treatment  lose  their  sight ;  while  we  may  be  permitted  to  inquire  whether 
any  beneficial  influence,  which  it  might  be  supposed  to  exert,  was  not 
really  due  to  the  rest,  darkness,  abstinence  from  stimulants,  and  cleanli- 
ness which  were  enforced  at  the  same  time.  That  it  ever  stayed  the 
course  of  the  disease  for  an  hour  I  very  much  doubt.  Thus,  for  instance, 
among  many  cases  of  utter  failure,  Sir  William  Lawrence  gives "  one 
where,  though  the  patient  was  bled  four  times,  cupped  on  the  back  of 
neck  and  temple,  dosed  with  tartar  emetic  so  long  as  it  could  be  borne, 
purged,  and  kept  on  low  diet,  "  no  sensible  effect  was  produced  on  dimin- 
ishing the  violence  of  the  inflammation  or  arresting  its  progress." 

Mr.  France,  in  a  highly  practical  paper,6  specifies  the  treatment  at 
Guy's  Hospital  as  consisting  in  division  of  the  external  canthus,  daily 
depletion  by  scarification  and  leeching,  the  use  of  a  six-grain  nitrate  of 
silver  collyrium,  unceasing  ablution  with  poppy- water  and  alum,  and  the 
internal  use  of  a  mercurial  such  as  Plummer's  pill,  quinine,  and  a  moderately 
nutritious  diet.  Mr.  Bader's  treatment,  as  communicated  to  the  British 
Medical  Association,8  consists  in  applying  to  the  entire  surface  of  the  con- 
junctiva an  ointment  composed  of  red  oxide  of  mercury,  sulphate  of 
atropin,  and  vaselin  in  the  proportions  of  one  grain,  a  fifth  of  a  grain,  and  a 
drachm.  The  ointment  is  thrust,  under  chloroform,  beneath  the  upper 
eyelid,  both  eyes  being  bound  up  with  lint  thickly  smeared  with  the  oint- 
ment.7 The  treatment  seems  to  have  been  very  successful.  In  one  case, 
where  the  eye  was  nearly  lost,  the  most  gratifying  results  were  derived 
from  the  use  in  this  way  of  daturin  and  nitric  oxide  of  mercury,  a  fifth  of 

'Vol.  ii.,  p.  287.  «Ibid.,  vol.  ii.,  p-  28.     1859. 

3  Dublin  Quarterly  Journal,  vol.  xxxiiii.,  p.  177.  4  Op.  citat.,  p.  71. 

6  Guy's  Hospital  Reports,  third  series,  vol.  iii. ,  p.  185. 

"British  MedicalJournal,  vol.  ii.,  p.  780.     1880.         "Lancet,  vol.  i.,  p;  675.     1880. 


TREATMENT.  265 

a  grain  each  to  an  ounce  of  vaselin,  the  quantity  of  the  mercurial  salt  be- 
ing afterward  increased  to  a  grain.  According  to  Dr.  Marcus  Gunn,1  an 
iced  compress  or  iced  alum-water  is  kept  constantly  applied  over  the  lids 
of  the  inflamed  eye,  and  a  solution  of  chloride  of  zinc,  gr.  ij.  to  §  j.,  is 
dropped  into  the  eye  from  three  to  six  times  in  the  twenty-four  hours  ac- 
cording to  the  amount  of  discharge.  The  sound  eye  is  protected  by  a 
Buller's  shield.  In  the  event  of  localized  cornea!  haze,  cold  poppy  lotion 
is  used  instead  of  the  iced  compress,  and  solution  of  sulphate  of  eserine, 
gr.  ij.  to  3J.,  is  dropped  in  six  times  daily.  He  does  not  find  that  the 
chloride  of  zinc  sets  up  the  irritation  which  might  be  expected  ;  he  speaks 
highly  of  the  action  of  eserine  in  true  deep  gonorrhoea!  ulcer.  Mr.  George 
Critchett,  in  a  case 2  which  seemed  desperate,  slit  up  the  upper  eyelid  as 
far  as  the  margin  of  the  eyebrow,  and  painted  the  affected  surface  three 
times  a  day  with  solution  of  nitrate  of  silver,  gr.  xxx.  to  |  j.,  with  the  best 
effects.  M.  Dor  mentions  3  a  case  in  which  extraordinary  success  attended 
the  use  of  solution  of  benzoate  of  soda,  first  recommended  I  believe  for 
this  purpose  by  Mr.  Graham  Browne,  one  part  in  twenty,  and  solution  of 
tannin,  one  in  ten  and  one  in  a  hundred.  The  patient  was  suffering  from 
double  purulent  ophthalmia,  but  was  relieved  the  next  day,  and  was  com- 
pletely cured  in  five  weeks,  the  cornea  remaining  intact  (!). 

Proposed  Plan  of  Treatment. — The  heading  here  is  only  adopted  in  order 
to  preserve  uniformity  of  plan,  as  my  experience  cannot  for  a  moment 
compete  with  that  of  gentlemen  attached  to  eye  hospitals.  Yet  the  treat- 
ment to  be  mentioned  rather  than  advocated  seemed  to  answer  fairly  well 
in  the  comparatively  few  cases  where  I  employed  it ;  indeed  I  did  not  ob- 
serve that  it  failed  when  the  patient  began  with  it  early  enough,  and  at- 
tended properly  to  the  instructions  given  him.  But  any  statement  of  this 
kind  is  to  be  coupled  with  the  reservation  that  there  are  two  sources  of 
fallacy  here  which  must  not  be  overlooked.  One  is  that  men,  who  are  even 
getting  on  very  well,  are  easily  persuaded  by  their  fears  or  their  friends  to 
go  to  an  eye-hospital ;  another  is,  that  very  possibly  the  worst  cases  are 
always  taken  there  from  the  first,  circumstances  which  invalidate,  any 
general  conclusions. 

The  internal  treatment  consists  of  free  use  of  sesqui-carbonate  of  am- 
monia in  infusion  of  cascarilla  or  snake-root,  a  calomel  pill  and  black 
draught  every  second  or  third  day,  and  opium  if  there  be  much  pain,  one 
or  two  grains  every  two  or  three  hours  till  the  pain  and  uneasiness  are 
thoroughly  checked,  sometimes  adding  a  very  small  quantity  of  calomel  to 
each  dose  ;  the  diet  light  and  warm.  But  I  could  not  undertake  to  say 
that  these  are  even  necessary,  as  I  have  never  trusted  to  internal  means 
alone,  relying  chiefly  on  the  nitrate  of  silver  in  solution,  four  grains  to  the 

1  London  Ophth.  Hospital  Reports,  vol.  x.,  p.  80.     1880. 

9  Lancet,  vol.  i. ,  p.  524.     1880. 

3  Lyoii  Med.,  March  7,  1880.    Quoted  in  London  Med.  Record,  p.  241.     1880. 


266  ON    GONORRHXEA. 

ounce,  ordering  it  to  be  dropped  in  two  or  three  times  a  day,  and  raising 
the  strength  rapidly  till  even  the  solid  nitrate  was  borne. 

If  there  be  any  chance  of  destruction  of  the  cornea,  free  incision  should 
be  resorted  to.  At  the  same  time  I  wish  it  to  be  understood  that  I  rec- 
ommend this  step  solely  on  the  authority  of  others,  and  that  in  my  own 
practice  the  necessity  for  it  has  never  arisen.  It  seems,  however,  pretty 
certain  that  the  practice  is  safe  enough.  M.  Robert  tells  us,1  that  M.  San- 
sun  used,  when  there  was  much  chemosis,  to  excise  ah1  the  conjunctiva  of 
the  eye  (toute  la  conjonctive  oculaire)  and  cauterize  the  bleeding  surface  with 
nitrate  of  silver,  and  this  with  a  result  which  surpassed  his  expectations. 
Complete  excision  of  the  chemosis  with  curved  scissors  had  indeed  been 
recommended  in  Lawrence's  day,  but  he  considered  2  it  impracticable,  and 
doubted  if  it  had  ever  been  performed.  Mr.  Tyrell,  who  was  a  very  good 
practitioner,  used  to  incise  freely. 

Of  external  applications  I  have  little  to  say.  I  have  myself  never  used 
any  but  an  evaporating  lotion,  containing  solution  of  the  acetate  of  am- 
monia and  spirit  of  wine  or  ether,  in  camphor  mixture  or  elder-flower 
water,  applied  to  the  forehead  and  eyebrow  by  means  of  a  single  fold  of 
linen.  I  believe  this  to  be  as  useful  as  any  such  means  can  be,  the  appli- 
cation being  often  very  grateful  to  the  patient ;  in  so  far,  too,  it  aids  the 
nitrate,  but  only  to  this  extent,  its  curative  power  being,  I  believe,-  next  to 
nothing.  I  never  myself  saw  inoculation  of  the  sound  eye  from  the  affected 
one  take  place.  In  the  very  few  instances  of  double  ophthalmia  which  have 
come  under  my  notice,  I  could  make  out  nothing  of  the  kind.  Dr.  Charles 
Taylor,  however,  observed  it  in  three  out  of  six  cases,  and  recommends  3  a- 
more  speedy  method  of  protecting  the  sound  eye  than  is  afforded  by  Bul- 
ler's  shield,  which  requires  some  little  time  to  make.  He  uses  a  pitch  plaster 
which  extends  over  the  eye  and  for  some  little  distance  beyond.  In  the 
centre  of  this  is  a  hole  for  -vision,  which  again  is  guarded  by  means  of  a 
piece  of  muslin  or  lace. 

b.  Gonorrhoea!  Iritis,  Pathology. — May  or  may  not  be  accompanied  by 
gonorrhceal  rheumatism,  seen  once  by  Eicord  without  joint  affection,  and  in 
one  eye  by  Fournier  in  a  patient  suffering  from  mild  gonorrhceal  oph- 
thalmia in  the  other  eye.  May  alternate  with  the  arthritis.  Generally 
seen  in  only  one  eye,  and  when  it  assails  both,  one  is  affected  after  the 
other.  It  attacks  principally  the  iris  and  other  internal  structures,  and  is 
not  accompanied  by  purulent  discharge  from  the  conjunctiva.  The  late 
Mr.  Eobert  Taylor,  in  a  brief  memoir  on  these  affections  which  he  drew  up 
for  me,  described  it  as  very  rare.  It  is  quite  unknown  to  me.  A  case, 
apparently  of  this  disorder,  is  reported  in  the  Gazette  Hebdomadaire  for 
1874.4 


1  Op.  citat.,  p.  244.  s  Op.  citat.,  p.  46. 

3  Medical  Times  and  Gazette,  vol.  i.,  p.  360.     1876.        4  Page  749. 


TREATMENT.  267 

Prognosis. — Seems  to  be  favorable,  but  cure  may  be  very  slow.  Founder 
says  weeks  may  elapse  before  resolution  begins.  Of  the  treatment  nothing 
very  special  is  said,  and  I  have  no  remarks  of  my  own  to  offer. 

c.  Rheumatism  of  the  Eyeball  (Sclerotitis),  Pathology.— ASects  the  scle- 
rotic, iris,  and  other  tissues ;  rather  a  common  disorder,  occurring  in  the 
proportion  to  purulent  ophthalmia  of  14  to  1,  almost  always  accompanied 
by  gonorrhoea!  rheumatism,  though  sometimes  the  eye  alone  is  affected, 
Ricord  having  seen  several  such  cases,  Fournier  three.     Pye-Smith  found  it 
7  times  in  29  cases  of  gonorrhoeal  rheumatism.    Most  frequently  accompanies 
rheumatism  attacking  several  joints,  Fournier  having  met  with  it  thus  23 
times  out  of  27  cases,  while  out  of  the  remaining  4,  3  occurred  with  mono- 
articular  rheumatism  and  1  with  sciatica.     Generally  attacks  both  eyes. 
First  made  clearly  known  by  Ricord,  though  Rollet  claims '  to  be  the  first 
who  connected  this  variety  with  gonorrhoea!  rheumatism,  which,  according 
to  him,  it  accompanies  about  once  in  every  ten  times.     It  is  not  dependent 
for  its  existence  on  weather,  habits,  or  a  first  attack  of  gonorrhoea,  for  it 
has  beeii  known  to  recur  four  or  five  times  in  the  same  person.     This  form, 
accompanied  by  purulent  discharge  from  the  conjunctiva,  is  the  only  affec- 
tion I  am  familiar  with,  arising   constitutionally  from  gonorrhoea.     I  have 
not  seen  it  in  the  female.     The  restriction  of  the  disease  to  the  male  sex  is 
denied  by  M.  Robert,2  who  maintains  that  it  may  be  seen  in  women. 

Prognosis. — Favorable.  I  never  found  the  affection  destructive  to  the 
eye  in  ray  practice  ;  in  point  of  gravity  is  widely  different  from  pure 
purulent  ophthalmia.  Mr.  Holmes  Coote,  however,  gives  a  case  clearly 
arising  from  this  source,  in  which  the  patient,  when  last  heard  of,  was  lying 
in  a  darkened  room,  with  the  eyesight  quite  unfit  for  useful  purposes,  and 
in  a  questionable  state  as  to  ultimate  recovery. 

Treatment. — Simply  that  of  gonorrhoeal  rheumatism,  supplemented  by 
the  daily  dropping  in  o'f  weak  nitrate  of  silver  solution  ;  if  the  patient  will 
allow  it,  the  lids  should  be  brushed  over  with  the  same  fluid.  Free  use  may 
be  made  of  spirit  lotions  over  the  eye.  With  all  possible  care,  the  cure  is 
apt  to  prove  tedious. 

d.  Aquo-capsiditis. — Described  I  believe  only  by  Fournier,  seen  but  once 
by  Tisier.     Slight  or  moderate  injection  of  conjunctiva  ;    cornea  intact, 
transparent ;  a  little  bulged  in  front,  more  brilliant  than  usual ;  sometimes 
tufts  of  deposit  on  posterior  surface  quite  close  to  this,  and  not  in  any  real 
connection  with  iris  ;  smoked  murky  look  of  anterior  chamber,  most  likely 
due  to  aqueous  humor  being  somewhat  charged  with  morbid  secretion  ; 
blood  may  be  effused  into  it,  but  both  cornea  and  iris  are  intact ;  vision 
slightly  confused,  objects  seen  dimly  and  as  it  were  enveloped  in  a  cloud  ; 
no  subjective  symptoms  or  only  a  feeling  of  stiffness  and  fulness  of  eye  ; 
photophobia  rare,  and  always  slight.     The  prognosis  seems  to  be  favorable  ; 
of  the  treatment  I  see  no  particular  account. 

'Op.  citat.,  p.  75.     1869.  *  Op.  citat.,  p.  156. 


268  ON    GONORRHOEA. 

20.  STRONG  TENDENCY  TO  BLEEDING  is  the  last  of  these  complications.  All 
those  persons  I  have  seen  affected  with  it  had  suffered  from  the  disorder 
of  the  liver.  The  mildest  injections  produced  bleeding  from  the  urethra, 
and  I  was  obliged  in  all  cases  to  abandon  them  until  this  tendency  gave 
way,  which  it  generally  did  in  a  little  while  under  the  use  of  aperients  and 
tincture  of  steel.  The  gonorrhoea  was  very  mild  in  these  patients.  This 
bleeding  is  not  like  that  from  injury  to  the  urethra ;  it  is  a  slight  but  very 
persistent  trickling. 

The  bleeding  generally  seen,  that  is  to  say  the  much  more  common  form, 
is,  in  nine  cases  out  of  ten,  due  to  neglect  and  want  of  rest.  The  conditions 
under  which  it  generally  occurs  point  so  clearly  to  the  treatment  required, 
that  I  should  scarcely  have  thought  it  necessary  to  say  more  than  that  they 
are  comprised  in  three  words — rest,  cold,  and  pressure.  Mr.  Cooke,  how- 
ever, mentions  a  case  where  the  surgeon  injected  tincture  of  iron  into 
the  urethra  to  check  the  bleeding,  and  succeeded  in  doing  so,  but  at  the 
same  time  coagulated  the  blood  into  such  a  firm  plug  that  an  opening  had 
to  be  made  behind  it  to  let  the  urine  out !  So  that  it  is  necessary  to  give 
due  notice  that  this  at  least  should  not  be  done. 


CHAPTEE  VII. 

PATHOLOGY  AND  TREATMENT  OP  GLEET. 

Pathology. — To  describe  the  symptoms  of  this  stage  of  the  disorder,  to  say 
that  it  is  the  declining  and  last  phase  of  gonorrhoea,  and  to  refer  its  per- 
sistency, when  obstinate,  to  some  constitutional  taint,  and  especially  to 
scrofula,  long  formed  the  staple  of  what  authors  had  to  tell  on  the  subject. 
But  indeed  it  was  not  then  an  easy  subject  to  investigate,  and  even  now 
requires  time  and  opportunities  which  every  one  cannot  command.  There 
being  no  strict  pathological  basis  to  go  upon,  I  have  been  accustomed  to 
adopt  an  arbitrary  one,  and  to  divide  the  affections  comprised  under  the 
name  of  gleet  into — 1.  Gonorrhoea  of  long  standing,  usually  owing  simply 
to  neglect.  2.  Inveterate  gonorrhoea,  which  is  merely  the  same  disorder 
in  a  more  rebellious  form  ;  generally  a  result  of  combined  neglect  and  mis- 
management. 3.  Gleet,  or  muco-purulent  gleet,  the  name  being  adopted 
solely  for  the  sake  of  distinction.  To  these  I  have  for  some  time  added — 
4.  Prostatic  gleet.  5.  Pure  mucous  gleet.  These  are  all  viewed  merely 
as  so  many  stages  of  the  same  process,  the  outcome  of  one  simple  specific  • 
disease  ;  prostatic  gleet  marking  the  extension  of  the  gonorrhceal  action  to 
the  follicles  of  the  gland,  and  simply  complicating  the  subject,  not  affecting 
its  intimate  nature.  It  is  to  be  remembered,  too,  that  any  such  arrange- 
ment as  that  above  is  only  useful  as  a  guide  to  treatment ;  no  classifica- 
tion of  gleet  has  been  or  is  likely  to  be  enduring. 

1.  GONORRHCEA  OF  LONG  STANDING. — In  the  first  of  these  divisions  the  dis- 
ease is  characterized  by  the  constant  presence  of  a  small  quantity  of  muco- 
purulent  discharge,  especially  on  rising  in  the  morning.     The  amount  is 
generally  not  great,  and  the  disorder  is  unaccompanied  by  much  chordee 
or  scalding,  though  there  may  be  tenderness  of  the  passage.     Often  the 
disease  is  so  limited  to  the  anterior  part  of  the  urethra  that  local  means, 
applied  to  this  part  of  the  canal,  suffice  to  cure  it ;  sometimes  we  encounter 
much  the  same  condition  as  in  the  next  class.    I  presume  Noggerath  would 
call  this  latent  gonorrhoea,  and  Hennig  evidently  thinks  '  that  the  term  is 
fitly  applied  to  a  tender  irritable  state  of  the  urethra,  when  only  a  drop  of 
"  gleet  juice,"  tripper-saft,  can  be  squeezed  out  by  pressure. 

2.  INVETERATE  GONORRHEA. — The  case  is  more  severe  in  the  second  class, 


1  Deutsche  medizinische  Woclienschrift,  S. ,  673.     1879. 


270  ON    GONORRHCEA. 

which  is  not  unfrequently  accompanied  by  some  scalding  and  pain,  the 
latter  often  most  marked  opposite  the  junction  of  the  under  side  of  the 
penis  and  scrotum  ;  if  recent,  often  combined  with  stricture,  but  if  of  some 
standing,  as  eighteen  months  to  two  years,  there  is  usually  none.  For  if 
stricture  do  come  on  in  these  bad  subjects,  it  soon  becomes  so  marked  as 
to  make  the  diagnosis  quite  certain  ;  if  at  the  end  of  six  months  the  canal 
remains  quite  free,  my  experience  is  that  it  will  be  equally  free  at  the  end 
of  a  year.  We  often  find  tender  spots  in  the  urethra,  one  perhaps  near 
the  lacuna  magna  or  occupying  its  floor  ;  one  near  the  bulb,  a  very  fre- 
quent seat ;  and  sometimes  one  of  pretty  large  extent,  but  not  much 
marked  sensibility,  at  the  anterior  end  of  the  prostatic  urethra. 

Such  spots  are  not  large,  and  often  the  tenderness  is  so  slight  that  the 
patient  does  not  suspect  their  presence  till  the  surgeon  passes  a  bougie, 
which  soon  reveals  their  existence,  and  sometimes  discloses  their  morbid 
nature  by  bringing  away  a  small  clot  of  mucus  from  their  surface,  or  dis- 
lodging threads  of  epithelium  which  are  afterward  passed  with  the  urine. 
These  clots  are  generally  to  be  found  near  the  bulb,  and  I  have  seldom  met 
with  more  than  one  at  a  time.  Their  shape  is  irregular,  and  their  bulk  not 
usually  greater  than  that  of  the  smallest  pea,  often  much  less,  but  I  have 
now  and  then  seen  one  las  big  as  a  small  hazel-nut.  In  muco-purulent 
gleet  and  prostatic  gleet,  these  tender  spots  are  sometimes  the  sole  evi- 
dence that  the  original  disease  is  not  entirely  cured,  and  incontinent  men 
may  remain  dormant  for  years  till  called  into  activity  by  connection  and 
excesses  at  the  table.  The  pain  and  the  obstinacy  of  the  discharge  in  this 
variety  are  sometimes  referred  by  the  patient  to  chordee  or  over-injecting. 

3.  MTJCO-PURTJLENT  GLEET  is  shown  chiefly  in  the  occasional  appearance 
of  a  drop  of  mucus,  whitened  by  a  slight  admixture  of  pus,  often  with  ap- 
pearance of  shreds  in  the  urine  ;  almost  invariably  associated  with  more  or 
less  stricture.  Sometimes  pricking  pains  in  the  urethra  are  complained  of, 
and  there  is  often  a  history  of  treatment  long  tried  in  vain.  To  this  class 
of  cases  may  be  added  those  where  the  discharge  is  thin,  or  seems  broken 
up,  as  if  some  portions  of  it  were  more  consistent  than  others,  or  is  slightly 
colored  with  brown. 

4  PROSTATIC  GLEET. — This  variety  arises  from  two  causes,  one  being 
that  of  boys  at  school  playing  tricks  with  themselves,  the  other  is  the  ex- 
tension of  gonorrhoea  backward.  When  the  discharge  is  fairly  established, 
I  know  of  no  tests  by  which  gleets  arising  from  these  different  sources  can 
be  distinguished.  In  cases  where  it  has  not  resulted  from  infection  the 
discharge  is  often  of  a  more  mucous  character,  but  I  have  seen  numerous 
instances  of  identity  of  appearance  from  both  modes  of  origin.  I  purpose, 
however,  to  deal  here  only  with  the  gonorrhceal  variety.  The  character- 
istic features  are  a  small  quantity  of  creamy  discharge,  usually  constant, 
but  occasionally  absent  at  times  for  months,  returning  again  and  again 
even  when  no  stricture  is  present ;  shreds  of  epithelium  showing  in  the 


PATHOLOGY  AND  TREATMENT  OF  GLEET.        271 

urine,  especially  that  voided  on  first  rising,  and  soreness  with  heat  on  pass- 
ing a  bougie  even  very  gently.  There  may  be  other  symptoms,  such  as 
sensation  of  heat  on  making  water,  shooting  toward  the  buttocks,  discom- 
fort in  the  prostate  after  standing  long,  and  sometimes  on  lying  down  or 
going  to  stool ;  but  we  may  encounter  the  disease  in  a  very  intractable 
form  without  any  symptom  of  the  kind. 

5.  PURE  Mucous  GLEET. — This,  the  last  division,  is,  according  to  my  ob- 
servations, much  less  common  than  any  of  the  preceding,  and  is  generally 
only  a  last  and  brief  stage  of  a  gonorrhoea  cut  short  in  a  moderate  space  of 
time. 

The  discharge  is  pure  transparent  mucus,  and  is  often  noticed  in  much 
greater  abundance  after  an  erection.  The  lips  of  the  urethra  are  some- 
times red,  but  there  may  be  no  other  morbid  sign  beyond  the  secretion, 
or  at  most  only  some  tenderness  of  the  passage.  The  patient  frequently 
reports  seeing  damp  stains  on  his  linen,  which  occasion  him  much  uneasi- 
ness. 

Dr.  Fessenden  Otis  arranges  1  the  conditions  on  which  the  continuance 
of  a  chronic  discharge  from  the  urethra  may  depend  as  follows.  1.  An 
enfeebled  state  of  that  portion  of  the  mucous  membrane  which  has  been 
the  seat  of  acute  inflammation,  the  degeneration  of  the  epithelium  thus 
set  up  being  continued  by  a  state  of  enervation.  2.  Localization  of  the 
disease  in  the  deeper  parts  of  the  urethra,  or  in  folds  of  the  mucous 
membrane,  or  in  the  mucous  crypts  or  follicles  ;  conditions  which  we  may 
encounter  after  those  in  the  first  section  have  been  set  right  by  appropriate 
treatment  3.  Granular  ulceration  in  the  canal,  following  complete  exfolia- 
tion of  the  epithelium  of  the  part  attacked.  4.  Alterations  in  the  course 
and  calibre  of  the  urethra. 

He,  however,  gives  another  cause  not  included  in  this  list,  and  that  is 
abnormal  openings,  bringing  parts  of  the  urethra  into  contact  with  the  air. 
On  one  occasion  he  found  two  of  these  close  to  the  meatus,  one  above  the 
other,  and  about  a  quarter  of  an  inch  apart ;  they  communicated  with  each 
other,  and  he  felt  confident  that  they  also  communicated  with  an  ulcerated 
patch  on  the  floor  of  the  lacuna  magna,  though  he  could  not  establish  the 
fact.  In  another  case,  that  of  a  patient  suffering  from  a  little  creamy  dis- 
charge, there  were  two  very  small  pustules  on  the  glans,  into  the  upper  of 
which  he  could  pass  a  probe,  and  then  a  hypodermic  syringe  carrying  a 
solution  of  indigo.  By  placing  a  piece  of  lint  in  the  lacuna  magna,  he  sat- 
isfied himself  of  the  communication,  as  the  lint  was  stained.  M.  Diday 
describes  a  similar  lesion  in  another  part  of  the  organ,  namely  the  oc- 
casional appearance  of  a  small  hole  in  one  lip  or  other  of  the  mouth  of 
the  urethra ;  this  is  the  opening  of  a  mucous  follicle  running  parallel  to 
the  urethra,  and  communicating  with  it.  Down  this  tract  a  needle  can 

1  New  York  Journal  of  Medicine,  vol.  i.,  p.  354.     1870. 


272  ON    GONORRHOEA. 

be  passed  for  some  little  distance.  It  is  apt  to  become  the  nestling  place 
of  obstinate  gonorrhoea,  and,  when  it  is  so  affected,  pressure  from  behind 
forward  will  cause  a  drop  of  muco-purulent  fluid  to  exude  from  it.  At 
times  the  inflammation  of  the  little  follicle  takes  on  an  acute  shape  of  some 
severity,  but  its  prevailing  character  is  obstinacy. 

In  persistent  discharge,  Dr.  Otis  says  he  is  led  to  suspect  a  granular 
condition  at  some  point  or  points  in  the  canal,  where,  from  abnormal  activ- 
ity of  the  morbid  processes,  the  mucous  membrane  has  been  completely 
stripped  of  its  epithelial  covering,  and  from  the  underlying  tissues  coming 
to  participate  in  the  process,  ulceration  has  resulted  (!).  At  a  certain  stage 
in  the  declining  inflammation,  little  papillae  sprout  from  the  plastic  lymph, 
which  has  been  exuded  to  repair  loss  of  tissue  ;  these  papillae  he  calls  gran- 
ulations. This  granular  condition  is  usually  indicated  by  a  local  tender- 
ness on  pressure,  or  on  passing  a  sound  or  ball-staff. 

Dr.  Otis  examined  the  urethra  by  means  of  tubes  of  hard  rubber,  va- 
rying in  length  from  an  inch  and  a  half  to  eight  inches ;  with  the  aid  of 
reflected  sunlight,  as  also  that  of  Tiemann's  lamp,  burning  kerosene  oil, 
holding  ten  grains  of  camphor  dissolved  in  each  ounce.  Though  I  do  not 
observe  him  saying  anywhere  positively  that  he  really  sees  this  granular 
state,  there  is  no  other  conclusion  to  be  drawn.  "Especially,"  he  remarks, 
"is  the  meatoscope  valuable  in  diagnosis  of  the  granular  condition  of 
the  urethra  previously  mentioned;"  and  again,  "the  favorite  seats  of  the 
granular  ulceration  of  the  urethra  are  in  the  natural  expansions  of  the 
canal  at  the  navicular  and  bulbous  portions,  evidently  invited  by  the  rich 
diffusion  of  crypts  and  follicles  in  the  ample  folds  of  these  parts."  This 
idea  is  upheld,  as  regards  the  seat  of  the  disease,  by  Dr.  Sands,  in  a  paper 
read  before  the  New  York  County  Medical  Society  ; ]  and,  as  regards  fre- 
quency of  granular  appearance  near  the  bulb,  by  M.  Rollet,2  who,  however, 
also  finds  granulation  and  granular  ulceration  in  the  prostatic  region.  Mr. 
Phillips  only  says,  rather  vaguely,  that  after  death  a  white  spot,  resembling 
the  cicatrix  of  an  ulcer,  is  sometimes  found  in  the  urethra  of  a  person  who 
has  suffered  from  gleet  during  life  ;  and,  from  the  context,  the  seat  of  this 
lesion  must  be  referred  to  the  lower  surface  of  that  part  of  the  canal  which 
lies  beneath  the  symphysis  pubis. 

While  rejecting  Dr.  Dick's  view,  that  many  cases  of  gleet  owe  their  per- 
sistence to  a  deviation  in  the  urethra  from  its  natural  line,  Dr.  Otis  assigns 
great  weight  to  even  a  very  slight  contraction  of  the  canal.  He  is  of  opin- 
ion that  many  of  those  cases  when  the  discharge  comes  on  from  venereal 
excitement,  or  where  it  occurs  in  a  few  hours  after  exposure  to  infection, 
are  due  to  stricture,  and  affirms,  as  an  important  axiom,  that,  "the  slight- 
est encroachment  upon  the  calibre  of  the  urethral  canal  is  sufficient  to 

1  Medical  Record,  p.  93.     No.  274. 
'Annales  de  Dermatologie,  tome  i. ,  p.  110. 


PATHOLOGY  AND  TREATMENT  OF  GLEET.        273 

perpetuate  a  urethra!  discharge,  or  even,  under  favoring  conditions,  to  es- 
tablish it  de  nouo  without  venereal  contact."  In  a  paper  read  before  the 
Medical  Society  of  London,  many  years  ago,  I  stated  my  reasons  for  be- 
lieving that  gleet,  complicated  with  deflection  of  the  canal  owing  to  peri- 
neal  abscess,  even  when  aUowing  a  full-sized  gum-elastic  bougie  to  pass,  is 
often  very  obstinate,  and  that  stricture  is  by  no  means  always  at  the  bot- 
tom of  recurrent  gleet,  as  has  been  alleged.  Finally,  I  may  observe  that 
gleet  is  sometimes  cured  without  the  complicating  stricture  being  removed.  • 

According  to  M.  Desormeaux,  as  quoted  by  Fournier,  gonorrhoea  will 
disappear  spontaneously  from  both  the  front  and  back  part  of  the  urethra 
while  it  continues  in  the  vicinity  of  the  bulb  ;  but  as  it  contracts  in  extent 
it  gains  in  depth.  Instead  of  simply  affecting  the  superficial  layer  of  the 
mucous  membrane,  it  attacks  the  whole  thickness  of  it,  insinuates  itself 
into  the  follicles,  and  even  reaches  the  subjacent  tissues,  bringing  on  in- 
duration, etc.,  thus  constituting  gleet.  But  in  a  great  number  of  such 
cases  I  have  found  that,  however  free  the  anterior  part  of  the  urethra  might 
be,  behind  the  bulb  was  extensively  affected. 

The  Endoscope. — What  little  I  have  to  say  on  this  part  of  the  subject  is 
borrowed  almost  entirely  from  others.  My  own  trials,  made  with  an  in- 
strument almost  exactly  like  that  of  Desormeaux,  kindly  lent  for  the  pur- 
pose, were  few  and  imperfect ;  but  such  as  they  were  they  thoroughly  dis- 
appointed me,  nor  have  I  recovered  faith.  The  exceedingly  small  surface 
illuminated,  the  dimness  of  the  light  cast  upon  it,  the  loss  of  time,  and  the 
discomfort  a  patient  must  necessarily  be  subjected  to  even  by  the  most 
expert  operator,  are  in  my  opinion  insuperable  obstacles  to  reliance  on  this 
instrument  for  our  diagnosis.  At  the  same  time  I  wish  to  bear  my  testi- 
mony to  the  skill  of  the  inventor,  and  to  the  careful  way  in  which  he  has 
worked  out  the  subject,  giving  an  impulse  to  scientific  exact  investigation 
which  has  already  yielded  most  valuable  fruits. 

Foremost  among  these  stand  the  admirable  labors  of  Herr  Auspitz,1 
who  has  vastly  extended  the  sphere  of  inquiry,  and  who  considers  that  en- 
doscopic  examination  has  become  a  necessity,  but  not  in  acute  gonorrhoea 
unless  there  is  strangury,  being  then  painful,  superfluous,  and  even  injuri- 
ous. When  the  disease  has  lasted  a  few  days,  and  is  not  accompanied  by 
much  swelling,  it  may  be  undertaken  ;  but  even  then  can  be  postponed, 
and  is  only  indispensable  when  the  gonorrhoea  has  lasted  from  six  to  ten 
weeks,  or  comes  back  without  manifest  cause,  as  also  in  recently  contracted 
cases  having  none  of  the  characters  of  the  acute  complaint.  He  recommends 
examining  with  Otis'  sound,  to  which  I  must  object  entirely. 

Auspitz  prefers  to  have  the  tube  separated  from  the  lighting  apparatus, 
and  uses  for  the  latter  a  standing  petroleum  or  gas  lamp,  without  concen- 
trating lens  ;  as  reflector  a  concave  mirror  on  a  footstalk  fixed  by  a  fillet 

1  Vierteljahresschrift  fiir  Dermatologie  und  Syphilis,  1  Heft.     1879. 
18 


274  ON    GONORRHCEA. 

He  rejects  the  curved  tube  of  Desormeaux,  preferring  straight  tubes  thir- 
teen and  a  half  centimetres  long,  which  by  manoeuvring  can  be  got  into 
the  bladder.  The  tubes  are  rounded  at  the  far  end,  and  brightly  polished 
inside.  When  the  bladder  is  to  be  examined,  an  obliquely  set  flat  glass  is 
used  to  keep  the  water  off.  There  must  be  at  least  three  diameter  sizes  of 
tubes,  and  different  lengths  are  required.  In  some  cases  it  is  necessary  to 
dilate  the  mouth  of  the  urethra  with  the  knife  !  To  examine  the  navicular 
fossa  only  a  short  tube  and  strong  light  are  requisite,  the  field  of  vision  be- 
ing cleared  by  means  of  a  plug  of  Brim's  wadding.  The  tube  he  now 
uses  is  really  a  two-bladed  speculum,  with  a  stem  to  guide  and  a  lever  to 
expand  it,  and  funnel-shaped  at  the  near  end.  The  instrument  is  made 
of  the  finest  steel,  polished  and  nickeled,  the  handles  and  funnel  being  black 
to  prevent  disturbance  from  reflected  light.  By  grasping  the  penis  and 
instrument  with  one  hand,  and  dilating  with  the  other,  the  whole  of  the 
urethra  can  be  seen  as  the  instrument  is  shifted  to  and  fro  ;  he  has  never 
had  the  folds  of  mucous  membrane  get  entangled  in  the  valves.  I  must 
pass  over  his  valuable  observations  as  to  the  form  the  urethra  assumes 
under  this  kind  of  examination,  both  in  the  natural  and  morbid  state,  so 
that  in  this  respect  the  present  epitome  is  highly  incomplete.  I  must  also 
omit  his  account  of  the  endoscopic  appearances  observed  by  Tarnowsky, 
Fenger,  Berkeley  Hill,  Grunfeld  and  Gschirhakl,  among  which  we  repeat- 
edly find  a  herpetic  urethritis,  a  thing  I  have  never  yet  seen,  and  pass  on 
to  Auspitz's  own  description  of  what  he  noticed.  As  text  he  takes  the  first 
form  of  gleet  defined  by  myself,  not  complicated  by  stricture  but  embrac- 
ing gleet  of  the  prostate. 

What  he  found  in  a  number  of  cases  was  injection  of  the  whole  or  parts 
of  the  mucous  membrane,  which,  in  the  region  corresponding  to  the  cor- 
pora cavernosa,  where  it  is  usually  rose-red,  appeared  of  a  dull  flesh  color, 
and  dull  red  where  it  usually  shows  only  of  dull  reddish  hue,  as  near  the 
bulb  ;  at  the  same  time  the  membrane  appeared  less  shining.  Along  with 
this  was  noticed  a  change  in  the  outline  of  the  urethra,  which  would  be 
unintelligible  without  reference  to  its  normal  shape  under  the  endoscope, 
and  is,  therefore,  reluctantly  left  out.  Field  of  vision  generally  covered 
with  mucus  and  threads  of  pus  ;  sometimes  in  cavernous  (spongy)  part  is 
seen  a  small  yellow-white  spot,  in  the  centre  of  a  round,  oval,  or  irregu- 
larly shaped  patch,  yielding  on  puncture  a  little  matter.  The  sound  then 
enters  a  small  pit,  which  can  be  recognized  as  one  of  Morgagni's  follicles 
converted  into  a  tiny  abscess.  Such  a  collection  of  matter  may  be  the 
source  of  an  obstinate  relapsing  gleet,  and  require  puncture  for  cure.  In 
uncomplicated  cases  the  symptoms  just  mentioned  do  not  usually  extend 
beyond  the  bulbous  part,  but  when  the  case  is  complicated  there  may  be- 
a  hemorrhagic  state  of  the  mucous  membrane  in  the  prostatic  part,  with 
change  of  shape  of  urethra. 

Such  are  the  appearances  most  commonly  met  with ;  in  more  developed 


PATHOLOGY  AND  TREATMENT  OF  GLEET.        275 

cases  there  may  be  swelling  of  the  mucous  membrane  of  different  degrees 
of  intensity ;  the  bulbous  part  usually  most  injected,  the  cavernous  part 
being  perhaps  nearly  returned  to  its  normal  state.  There  may  also  be 
changes  in  the  structures  of  the  bulbous  part,  the  mucous  membrane  dull, 
moist  looking  and  slightly  puffed,  giving  appearance  of  little  elevations 
which  make  the  walls  of  the  urethra  mulberry  or  velvety  looking.  The 
dull  look  noticed  in  the  bulbous  part  may  also  be  seen  in  the  spongy  por- 
tion, not,  as  Desorrneaux  and  his  successors  assert,  in  the  shape  of  a  soli- 
tary granulation  islet,  but  not  unfrequently  in  several  connected  patches  ; 
occasionally  smooth  patches  covered  with  secretion  are  seen,  or  accumula- 
tions of  epithelium  near  the  mouth  of  the  urethra.  Appearances  similar  to 
those  in  the  bulbous  portion  may  also  be  found  in  the  membranous  and 
beginning  of  prostatic  parts  ;  but  while  an  unhealthy  spot  only  bleeds  ex- 
ceptionally at  the  bulbous,  and  very  rarely  at  the  spongy,  part,  a  very 
slight  injury  will  make  the  membranous  portion  bleed  so  as  materially  to 
interfere  with  examination.  He  is  not  satisfied  that  the  dull  places  on  the 
mucous  membrane  are  due  to  loss  of  substance,  but  has  observed  that  cer- 
tain superficial  ulcerations  (exfoliations),  dull  depressions  with  a  special 
reflected  outline  (dunkle,  von  einer  eigenen  Eeflexfigur  umschlossene  Ver- 
tiefungen),  are  more  frequent  than  in  front.  When  these  appearances  are 
observed,  the  sensitiveness  of  the  canal  is  much  increased.  Such  a  "  find  " 
(Befund)  may  also  be  observed  in  the  prostatic  part. 

Auspitz  does  not  consider  granulation  associated  with  contagion ;  the 
process  thus  called  by  Desormeaux  occurs  mostly  in  the  bulb  and  mem- 
branous parts,  may  also  be  found  in  the  spongy  part,  and  near  the 
mouth.  The  morbid  change  is  most  usually  confined  to  an  isolated  and 
solitary  part,  but  may  be  diffused  over  the  whole  of  the  spongy  portion. 
He  seems  to  have  repeatedly  found  exfoliation  of  epithelium  from  the 
urethra.  The  granulations,  or  rather  I  should  say  what  are  wrongly  called 
such,  are  found  most  frequently  at  wbat  is  so  often  the  site  of  stricture, 
that  is  to  say  the  bulb  and  membranous  part ;  but  he  very  properly  re- 
jects the  view  of  Desormeaux  that  cicatricial  strictures  arise  from  ulcer- 
ation  of  the  granulations.  I  say  veiy  properly,  as  all  I  have  observed 
leads  me  to  believe,  that  in  many  instances  at  least  the  contraction  takes 
place  first  and  that  the  changes  of  stricture  follow.  Equally  he  does  not 
allow  that  stricture  can  be  traced  to  degeneration  of  the  granular  forma- 
tions. The  granular-looking  swellings  seen  in  the  urethra  are  not  neces- 
sarily referable  to  granulation.  He  considers  simple  catarrhal  action  suf- 
ficient to  explain  all  that  is  seen  in  the  canal,  and  the  symptoms  set  up  by 
catarrh  are  serious  swelling,  abnormally  rapid  growth  and  thickening  of 
the  upper  layers  of  tissue,  changes  which  penetrate  deeper  and  deeper  till 
they  reach  the  submucous  structures.  The  pathological  effect  of  this  is 
appearance  of  an  uneven,  granular  grained  surface.  Even  with  stricture 
he  found  mostly  hypeiwmia,  with  swelling,  spotty,  grained  state  of  mem- 


276  ON    GONORRHCEA. 

brane  and  strong  tendency  to  bleeding ;  not  a  stiff  cicatricial  connective 
tissue,  but  soft,  loose,  and  compressible  connective  tissue,  which,  however, 
may  clearly  pass  into  the  former,  and  this  morbid  change  may  extend  all 
over  the  mucous  membrane  and  even  penetrate  into  the  tissue  substances 
of  the  cavernous  bodies,  thickening  them  and  wasting  their  meshes. 

Herr  Auspitz  totally  and  on  good  grounds  rejects  croupy,  papillary, 
granular,  follicular  forms  of  urethritis.  He  thinks  therapeutics  have  gained 
by  the  introduction  of  the  endoscope ;  we  shall  be  able  to  see  a  greater 
number  of  cases  at  the  critical  period  between  the  catarrhal  stage  and  the 
atrophic  process.  But  except  in  the  fact  which  he  mentions,  that  relapse 
often  means  swelling  of  one  of  the  follicles  of  Morgagni,  which  requires 
opening  and  touching  at  the  edges  with  caustic,  I  do  not  see  much  which 
promises  either  practically  or  theoretically  to  yield  better  results  than  the 
treatment  laid  down  in  these  pages,  while  there  are  some  points  of  doctrine 
to  which  I  cannot  quite  assent.  For  instance  he  fixes '  eight  weeks  as  the 
time  for  a  gonorrhoea  to  be  allowed  to  run  before  the  endoscope  is  resorted 
to,  which  I  consider  much  too  long. 

Dr.  Amilcar  Kicordi,  of  Milan,  has  contributed  a  highly  practical  and 
valuable  memoir a  on  gleet  of  Cowper's  ducts,  of  which  he  distinguishes 
two  kinds ;  one  in  which  the  urethra,  on  pressure,  yields  two  or  three 
small  drops  of  opaline  fluid,  of  the  density  of  white  of  egg,  frothing  on 
being  rubbed  between  the  fingers.  Examined  with  the  microscope  this 
product  gives  mucous  corpuscles,  cellules  of  pavement  epithelium,  and 
amorphous  liquid  matter.  Under  the  influence  of  sexual  excitement,  the 
secretion  may  become  muco-purulent.  The  second  form  is  simply  what 
we  call  gleet,  a  little  discharge  appearing  at  the  mouth  of  the  urethra  when 
the  patient  rises  in  the  morning. 

I  do  not  know  whether  I  render  Dr.  Eicordi's  views  correctly,  as  the 
paper  is  in  some  parts  rather  difficult  to  follow,  but  I  understand  him  to 
say  that  in  the  first  variety  the  ducts  alone  are  involved,  in  the  second  the 
urethra  participates.  The  shreds  thrown  out  in  true  gleet  of  the  ducts  are 
cylinders  of  epithelium,  casts  of  the  ducts.  There  are  always  two  of  them, 
and  they  are  covered  with  a  very  fine  diaphanous  membrane  ;  whereas  the 
shreds  of  stricture,  slight  catarrh  of  the  bladder  and  newly  cured  gonor- 
rhoea have  no  epithelial  covering,  and  resemble  rather  little  flakes  or  tufts 
than  threads.  The  secretion  from  the  ducts  is  also  unlike  that  from  the 
prostate,  which  consists  of  filiform  concretions  one  or  two  lines  long, 
fringed  at  one  end,  thicker  and  entire  at  the  other,  often  accompanied  by 
the  presence  of  brownish  bodies,  which,  on  squeezing,  yield  polygonal 
cells  and  "brownish-clear"  nuclei.  Dr.  Visconti  twice  examined  the  secre- 
tion of  the  ducts,  and  found  in  one  specimen  mucous  corpuscles  in  mucine, 
some  of  them  in  a  state  of  fatty  degeneration,  with  cells  of  pavement  epithe- 

1  Op.  citat,  p.  70.  5  Giornale  italiano,  vol.  ii.,  p.  129.     1874. 


PATHOLOGY  AND  TREATMENT  OF  GLEET.        277 

Hum  among  them.     In  the  second  there  were,  in  addition  to  these  pro- 
ducts, crystals  of  carbonate  of  lime. 

Sometimes  in  this  gleet,  when  the  urine  has  passed  the  bulb,  there  is  a 
slight  hitch,  and  if  an  instrument  be  introduced  the  patient  complains  of 
a  sense  of  heat.  The  sense  of  formication  noticed  in  other  forms  of  gleet, 
and  even  when  there  is  no  discharge  present,  as  also  the  sensation  of  a 
drop  of  water  falling  from  the  bulb  into  the  urethra,  may  be  present  in 
this  variety  ;  but  the  shreds  are  the  pathognomic  sign,  and  are  always  to 
be  noticed  on  rising.  If  the  patient  make  water  before  removing  the  drop 
of  pus  at  the  mouth  of  the  urethra,  or  which  can  be  made  to  appear  there 
by  a  little  pressure,  they  will  be  found  in  the  vessel,  and  if  the  drop  be 
first  of  all  cleared  away  they  are  wanting.  This  form  of  gleet  is  apt  to  be 
extremely  obstinate,  and  cannot  be  met  by  the  ordinary  means  of  treat- 
ment. Persistency  of  it  he  attributes  to  unusual  length  of  the  ducts,  which 
he  has  found  much  greater  in  some  pathological  specimens  than  in  others. 

Ricordi  mentions  a  case  of  this  disorder,  which  I  think  supports  the 
theory  of  there  being  a  wide  distinction  between  idiopathic  and  acquired 
purulent  discharge  from  the  urethra.  It  is  that  of  a  man  in  whom  the 
affection  -had  been  brought  on  by  long-continued  venereal  excitement  with- 
out infection,  and  in  whom  it  ran  so  mild  a  course,  that  Ricordi  did  not 
think  fit  to  order  more  than  a  simple  injection,  whereas  we  have  just  seen 
how  obstinate  he  found  the  affection  when  derived  from  gonorrhoea. 

Prognosis.- — Usually  favorable  in  the  long  run  when  the  case  is  properly 
treated.  Even  when  complicated  with  stricture  it  may  almost  always  be 
subdued.  Prostatic  gleet  is  sometimes  very  obstinate,  as  is  that  in  which 
there  is  a  history  of  deviation  in  the  urethra,  caused  by  unabsorbed  de- 
posit, the  result  of  perineal  abscess.  In  cases  of  sinuses  communicating 
with  the  urethra  and  external  surface,  all  treatment  may  prove  ineffectual. 
The  possible  effects  of  such  a  contingency  duly  allowed  for,  I  do  not  share 
M.  Fournier's  view  '  that  gleet  may  endure  for  life.  With  all  this  its  pro- 
verbial obstinacy  has  scarcely  been  over-rated. 

Treatment.  A.  In  the  Male. — How  then  are  we  to  master  this  refrac- 
tory disorder  ?  M.  Ricord,  looking  to  the  possibility  of  having  to  spend 
his  future  existence  in  the  land  of  the  damned,  seems  to  think  that  what 
he  has  most  to  dread  is,  not  the  discomfort  of  the  abode,  but  the  certainty 
of  being  plagued  by  the  ghosts  to  cure  them  of  their  gleets.  But  if  the 
contingency  be  an  imaginary  one  for  the  next  world,  it  is  a  reality  here, 
and  sometimes  a  very  troublesome  realit}'.  At  first  sight  nothing  seems 
easier  to  cure  than  the  gleet ;  yet  few  slight  complaints  are  more  difficult 
to  subdue,  and  the  number  of  remedies  suggested  by  authors  only  proves 
how  often  all  their  resources  have  failed. 

Some  authors,  Graves,  Ricord,   Whately,  Phillips,  Fournier,   for  in- 

1  Nouveau  Dictionnaire,  tome  v.,  p.  150. 


278  ON    GONORRHOEA. 

stance,  candidly  confess  that  they  have  met  with  instances  where  the  dis- 
ease did  not  yield  to  any  treatment ;  but  others  are  rather  careful  how 
they  commit  themselves  to  any  very  decided  statements.  The  manner, 
however,  in  which  the  subject  has  been  handled,  leaves  no  doubt  on  the 
mind  of  the  reader,  that  the  authors  in  question  are  quite  familiar  with 
those  obstinate  cases  which  go  on  for  months,  or  even  years,  till  at  last 
the  patient  gets  so  thoroughly  sick  of  medicines,  that  he  makes  up  his 
mind  to  endure  an  evil  he  cannot  remedy.  Or,  perhaps,  if  the  sufferer  be 
an  Englishman,  he  betakes  himself  to  the  quack,  while  the  German  starves 
and  injects  petroleum  ;  recklessness,  indeed,  being  according  to  Dr.  Carl 
Pauli  1  common  to  people  suffering  from  urino-genital  affections.  The 
Italian,  according  to  Dr.  Eicordi,  becomes  hypochondriac  and  desperate  ; 
and  our  lively  neighbor,  the  Gaul,  takes  the  affair  still  more  to  heart ;  for 
M.  Robert  tells  us  that  he  not  unfrequently  conceives  a  disgust  for  the 
world,  goes  mad,  or  decides  that  suicide  is  better  than  to  be  always  taking 
copaiba,  cubebs  and  alum,  tar- water,  and  creosote,  besides  being  made  the 
subject  of  interesting  experiments  with  the  last  new  drug  ;  the  whole 
forming  a  rather  sarcastic  commentary  on  the  many  infallible  methods  of 
cure  recommended  for  this  complaint,  and  offering  a  suggestive  hint  to  all 
but  those  who  are  insensible  to  ridicule,  as  is  the  case  with  the  infallible 
section  of  mankind.  Under  these  circumstances  I  hope  to  stand  excused 
for  devoting  a  little  extra  attention  to  the  questions  involved. 

The  following  digest  will,  I  think,  comprise  the  pith  of  all  the  direc- 
tions given  by  those  authors  I  have  consulted : — The  specific  remedies  hav- 
ing failed,  they  may  be  tried  combined  or  along  with  steel  or  cantharides  ; 
then  the  bougie,  simple  or  armed,  the  latter  being,  when  of  any  service, 
often  intensely  painful,2  often  failing,  and  almost  invariably  requiring  to- 
be  repeated ;  violent  exercise  ;  a  course  of  tonics,  or  one  of  Zittman's  de- 
coction is  to  be  used,  or  the  urethra  may  be  cauterized ;  these  failing, 
constitutional  treatment  is  to  be  suggested,  or  change  of  air,  sea-bathing, 
or  the  cold  plunge  bath,  or  perhaps  an  alterative  course  of  mercury.  Fin- 
ally, we  are  told  of  cases  where  the  coup-de-grdce  has  been  given  to  the 
rebellious  disease  by  some  desperate  remedy,  such  as  the  rude  passing  of 
a  bougie,3  an  injection  of  brandy,  a  violent  debauch,  a  drastic  purgative,4 
a  seton,  or  a  blister  to  the  perineum — so  that  the  despairing  reader  has  a 
method  of  getting  out  of  the  difficulty  equally  useless  to  himself  and  to 
the  patient. 

It  is  very  safe  to  go  into  generalities,  to  offer  simply  collective  experi- 
ence, but  it  does  not  meet  the  difficulties  of  the  subject.  A  surgeon,  who 

1  Deutsche  medizinische  Wochenschrift,  S.  64.     1875. 

2  Mr.  Johnson,  one  of  the  advocates  for  the  practice,  candidly  admits  this. — Op. 
citat.,  p.  100.     He  also  says  that  it  is  apt  to  induce  inflammation  of  the  testicle  or  blad- 
der, and  has  seen  bad  stricture  from  it. 

3Swediaur,  Op.  citat.,  p.  66.  *  Hunter,  Op.  citat.,  p.  77. 


PATHOLOGY  AND  TREATMENT  OF  GLEET.         279 

has  an  obstinate  gleet  to  cure,  does  not  feel  much  wiser  after  reading  over 
a  list  of  remedies  which  would  take  two  or  three  years  to  become  thor- 
oughly acquainted  with. 

Now,  when  a  case  of  gonorrhoea  or  gleet  has  been  regularly  treated  for 
thirty  days,  and  at  the  end  of  that  time  is  no  better ;  when  during  all  this 
time  the  surgeon  has  reason  to  think  that  the  patient  has  given  the  treat- 
ment fair  play,  and  finally,  if  there  be  no  complication,  such  as  swelled 
testicle  or  abscess  in  the  perineum,  my  opinion  is  that  it  will  not  be  cured 
by  the  ordinary  remedies  more  than  once  in  fifty  times  ;  nay,  I  question  if 
any  benefit  result  from  employing  them,  and  could  we  attain  to  a  suffi- 
ciently accurate  diagnosis  at  the  outset,  it  would,  I  think,  be  better  to  re- 
sort at  once  to  a  different  plan.  But  I  know  of  no  means  of  doing  this — 
and  the  only  rule  I  can  find  for  using  extraordinary  measures  is  the  fail- 
ure of  others. 

Again  and  again  have  I  in  such  cases,  at  the  wish  of  the  patient,  or 
from  a  desire  to  avoid  recurring  to  my  last  resource,  tried  one  medicine 
after  the  other,  and  injections  of  all  kinds.  The  result  always  was,  either 
that  the  patient  left  uncured,  that  some  complication  sprung  up,  or  that  a 
cure — if  effected  at  all — was  wrought  by  some  totally  different  means.  I 
have  long  given  up  this  plan,  convinced  that  if  one  'medicine  fail,  a  second 
has  just  as  little  chance. 

It  may  be  said  that  this  is  a  very  short  time  to  fix  for  a  trial,  but  I  can 
scarcely  recall  a  case  of  cure  being  effected  by  medicine  where  there  were 
no  signs  of  amendment  within  a  month.  Delay,  too,  is  perilous  ;  while  we 
are  trying  to  cure  the  discharge,  stricture,  at  the  bottom  of  the  mischief, 
may  be  gaining  ground. 

When  a  patient  with  long-standing  gleet  only  comes  under  our  care 
at  an  advanced  stage,  the  first  step  of  all  is  to  make  out  the  history  of  the 
treatment.  Many  of  these  cases  last  so  long  solely  because  no  pains  have 
been  taken  to  secure  a  different  result. 

Thus,  in  one  case  the  disorder  had  continued  twelve  months,  but  the 
patient  had  only  taken  pure  copaiba  and  sweet  spirit  of  nitre  :  a  cure  was 
effected  in  three  weeks  by  the  daily  use  of  an  injection  of  nitrate  of 
silver.  In  a  second,  the  gonorrhoea  had  lasted  five  months,  but  on  cross- 
questioning  the  patient,  he  admitted  having  neglected  it ;  it  was  cured  in 
a  few  days  by  mild  aperients  and  sulphate  of  zinc  injections.  In  a  third, 
the  patient  said  he  had  had  it  off  and  on  for  eighteen  months.  His  plan 
had  been  to  go  to  a  surgeon  for  three  or  four  months,  and  if  not  relieved 
to  betake  himself  to  another  ;  thus  perpetually  beginning  treatment  anew. 
He  reaped  the  results  in  the  form  of  a  stricture.  A  fourth  patient  had 
been  treated  at  intervals  for  twelve  months  by  injections,  and  at  the  end  of 
the  time  had  not  learned  to  give  himself  an  injection  properly. 

This  preliminary  point  being  disposed  of,  I  proceed  to  consider  the 
treatment  of  the  different  varieties  of  gleet. 


280  ON    GONORRHCEA. 

First  Class. — Gonorrhoea  of  long  Standing, — This  form  of  gleet  will 
generally  yield  to  a  mild  aperient,  as  the  infusion  of  rhubarb  with  soda, 
and  an  injection  of  sulphate  of  zinc  two  or  three  times  a  day.  But  if.  at 
the  end  of  ten  to  fifteen  days,  no  improvement  has  been  effected  by  these 
or  any  other  means,  the  bougie  may  at  once  be  passed  ;  for  every  variety 
of  discharge  may  be  accompanied  by  more  or  less  stricture,  and  the  only 
sure  proof  of  no  contraction  being  present  is  that  a  bougie  wiU  pass. 
Should  this  exist,  it  is  needless  to  say  that  it  requires  its  special  treatment. 
But  if  no  stricture  be  found,  my  advice  would  be  to  have  immediate  re- 
course to  the  long  syringe,  and  to  carry  the  injection  to  the  prostatic  part 
of  the  urethra.  Nor  is  any  harm  to  be  apprehended  from  allowing  the 
injection  to  spread  a  little  farther  than  the  focus  of  mischief,  the  neighbor- 
ing parts  of  the  urethra  being  usually  in  a  state  which  is  rather  benefited 
than  otherwise  by  the  nitrate  ;  at  least  this  has  often  been  the  case  in  my 
own  practice.  Thirty  to  forty  minims  are  thrown  into  the  canal.  To  the 
objection,  which  has  been  made,  that  even  this  quantity  is  excessive,  that 
no  object  is  served  by  letting  a  caustic  solution  flow  over  the  anterior  part 
of  the  passage,  and  that  the  same  good  would  be  gained  by  injecting  six  or 
seven  drops  at  the  bulb  or  prostate,  I  reply  that  I  have  never  seen  any 
mishap  from  this  excess ;  that  the  inconvenience  of  having  an  apparatus, 
such  as  that  required  for  injecting  so  small  a  quantity,  and  of  measuring 
the  spot  in  the  urethra  where  this  must  go,  is  far  greater  than  by  my 
method  ;  that  caustic  solutions  should  not  be  employed ;  and  that  no  mis- 
chief ever  follows  from  letting  a  weak  solution  flow  out  of  the  meatus. 
Half  a  grain  to  a  grain  of  the  nitrate,  in  an  ounce  of  distilled  water,  is  quite 
enough  to  begin  with,  and  when  the  patient  states  that  he  is  very  sensitive 
to  pain,  even  a  weaker  solution  should  be  employed.  But  generally  these 
patients  bear  injecting  fairly  well ;  the  urethra  has  long  ceased  to  be  very 
susceptible  of  the  action  of  such  remedies,  and,  with  a  little  caution,  the 
strength  of  the  fluid  can  be  easily  raised  to  five  or  ten  grains  to  the  ounce. 
Pain,  however,  to  any  great  extent  is  a  mistake. 

Whichever  form  of  syringe  be  adopted,  I  would  suggest  that  two  or  three 
injections  should  be  given  with  it  in  pretty  rapid  succession,  and  then  that 
a  period  of  rest,  say  for  two  or  three  weeks,  be  observed,  during  which  the 
bougie  may  be  passed  every  five  or  six  days.  I  recommend  the  latter  both 
because  this  instrument  possesses  some  remedial  power,  and  because  the 
use  of  it  removes  the  little  clots  of  mucus  which  here  and  there  cover  a  ten- 
der spot  in  the  urethra.  Unless  this  is  done,  injections  may  be  given  long 
enough  without  effecting  much  good.  The  force  of  the  stream  from  the 
syringe  does  not  appear  great  enough  to  displace  the  clots,  and  the  solution 
merely  flows  over  them,  causing  imperfect  coagulation  without  touching 
the  half  abraded  surface  below.  These  clots  will  continue  to  form  for  years, 
and  as  there  seems  in  some  persons  no  natural  disposition  in  the  urethra 
to  get  rid  of  them,  it  becomes  highly  necessary  to  remove  such  an  obstacle. 


PATHOLOGY  AND  TREATMENT  OF  GLEET.        281 

In  close  connection  with  this  part  of  the  subject  it  will  perhaps  be  best 
to  notice  here  some  modes  of  treating  gleet  in  which  cold  figures  promi- 
nently ;  there  is  such  a  strong  family  likeness  running  through  these  sys- 
tems that  I  prefer  to  take  them  altogether.  The  earliest  recommendation 
to  this  effect  known  to  myself  is  by  a  writer  in  the  Practitioner,1  Mr.  Wind- 
sor's method  being*principally  suggested  for  gonorrhoea,  who  says  "  we  have 
frequently  succeeded  in  curing  chronic  blennorrhoea,  when  many  other 
means  had  been  tried  and  failed,  by  directing  the  patient  to  wash  out  the 
urethra  with  cold  spring  water  every  hour  throughout  one  or  two  days." 
A  somewhat  similar  practice  was  advocated  "  by  Mr.  Reginald  Harrison,  the 
fluid  being  applied  by  means  of  an  instrument  similar  to  that  which  Mr. 
Windsor  had  described.3  Other  satisfactory  accounts  have  been  given,  so 
that  there  seems  no  reason  to  doubt  that  a  certain  amount  of  success  has 
been  achieved  in  this  way  ;  but  judging  from  the  experience  of  Winternitz,4 
and  from  the  effects  ascribed  to  the  use  of  bougies  dipped  in  iced  water,  it 
would  seem  that  the  employment  of  a  cold  solid  body  is  quite  as  useful 

There  can  be  no  harm  in  ordering  a  tonic,  such  as  quinine  or  iron,5  along 
with  an  aperient,0  especially  if  the  health  happen  to  be  out  of  sorts,  as  is  ex- 
tremely apt  to  be  the  case  when  the  patient  has  been  long  trying  to  master 
the  running  by  means  of  specifics.  A  patient  who  has  suffered  in  this  way 
is  often  reassured  by  such  a  step,  and  some  persons  like  to  give  internal 
means  a  fair  trial  before  resorting  to  instruments.  They  are  often  better, 
and  never  worse,  for  a  proper  use  of  such  medicines,  and  a  man  in  good 
health  gets  rid  of  gleet  and  stricture  as  quickly  as  if  he  were  low  and  weak. 
Such  remedies,  then,  may  be  advantageously  prescribed  for  the  purpose  of 
relieving  exhaustion  and  setting  right  disordered  health  ;  as  regards  any 
power  over  the  discharge,  they  might  as  well  be  recommended  in  cancer 
or  hydrophobia. 

The  Bougie. — But  it  may  happen  that  we  find  some  degree  of  stricture, 
and  that  we  have  to  treat  it  before  we  can  do  anything  for  the  gleet,  so  that 
it  becomes  necessary  to  discuss  the  best  method  of  dealing  with  this  com- 
plication. Pi*ior  to  entering,  however,  upon  this  part  of  the  subject,  I  must 
beg  the  reader  to  understand,  that  what  I  have  to  say  does  not  apply  to 
stricture  generally,  and  particularly  to  bad,  advanced,  and  complicated 
cases  ;  but  to  that  stage  of  it  which  we  find  as  a  cause  or  complication  of 
inveterate  gonorrhoea  and  gleet,  which  is  seldom  severe  and  might  often  be 
described  rather  as  nascent  than  existing. 


'Vol.  vii.,  p.  48.     1871.          « Lancet,  vol.  i.,  p.  760.     1880.  3  Ibid.,  p.  901. 

4  Berliner  klinische  Wochenschrift.  S.  401.     1877. 

*  5.  Quinise  sulphatis,  gr.  xij.  (xxiv.);  magnes.  sulph.,  3  i%.;  acidisulph.  diluti,  Z  j.; 
tinct.  cardam  compos,  "  iv.  ;  aquae  cinnam.  ad  |  vj.  M.  Capiat  cochlear.  ampl.  bis 
terve  quotidie.  fy.  Tinct.  ferri  sesquichlorid.,  §  j.  Capiat  minim,  xxx.  ter  quotidie  et 
aquae  cyatho  vinar. 

'  H.  Pilulae  aloes  et  myrrlue,  vel  pilulae  rhei  comp.,  3  j.  Divide  in  pil.  xij.  Capiax 
j.  vel  ij.  horo.  decubitura. 


282  ON    GONORRHOEA. 

After  having  tried,  and  seen  tried,  most  of  the  systems  in  modern  use,  I 
feel  myself  compelled  to  say,  that,  as  a  rule,  all  such  operations  as  sudden  ex- 
KB  pansion  of  the  stricture,  or  division  of  it  internally  or  externally,  are 
here  almost  always  unnecessary,  and  only  too  often  dangerous ; 
that  they  effect  no  purpose  which  cannot  be  gained  more  safely  and 
painlessly  by  means  of  dilatation  with  the  bougie  to  be  presently  men- 
tioned, seconded  by  application  of  nitrate  of  silver,  and  that  at  least 
nine  times  out  of  ten  they  are  superfluous,  inasmuch  as  the  patient 
has  ultimately,  whatever  operation  be  performed,  to  trust  to  gentle 
dilatation.  I  should  be  very  sorry  to  offend  any  one  by  expressing 
this  opinion  ;  I  am  quite  ready  to  bear  ample  testimony  to  the 
value  of  the  inventions  of  Mr.  Thomas  "Wakley  and  Mr.  Barnard 
Holt,  and  to  that  of  the  operation  devised  by  the  late  Mr.  Syme, 
but  I  must  adhere  to  the  view  I  have  expressed.  The  results,  as 
detailed  to  me,  of  forcing  stricture  by  means  of  the  dilator  in  the 
posterior  part  of  the  urethra  have  been,  in  some  unfortunate  cases, 
severe  pain,  bleeding,  abscesses  in  the  perineum,  pysemia,  followed 
in  one  case  by  affection  of  the  hip-joint,  the  exact  nature  of  which 
I  could  not  learn,  but  which  resulted  in  stiffness,  apparently  per- 
manent, of  the  joint ;  more  or  less  complete  impotence  has  also 
followed.  To  dilatation  of  the  stricture  in  the  more  anterior  part 
of  the  canal  I  see  less  objection,  and  have  myself  frequently  em- 
ployed it. 

I  would  therefore  recommend,  as  a  first  step,  that  a  proper 
bougie  be  chosen.  I  give  the  preference  to  the  bougies  made, 
under  my  directions,  by  Walters  &  Co.,  both  on  account  of  the 
shape,  which  is,  to  my  thinking,  better  adapted  for  finding  its  way 
through  a  stricture  than  that  in  ordinary  use,  and  of  the  material, 
which  is  so  soft  that  no  mischief  can  be  done  to  the  walls  of  the 
urethra,  while  it  is  so  strong  that  the  dangers  attendant  on  the 
use  of  those  mischievous  implements,  gutta-percha  bougies,  and 
the  cheaper  class  of  French  instruments  sent  over  to  this  coun- 
try, are  got  rid  of.  As  to  first  of  all  passing  a  wax  bougie,  a  bougie- 
a-boule,  or  any  other  implement  of  the  kind,  I  hold  it,  with  ah" 
deference  to  the  gentlemen  who  advocate  the  plan,  to  be  totally 
unnecessary.  A  surgeon  whose  hand  is  properly  trained — and  no 
other  ought  in  such  a  case  to  attempt  to  pass  a  bougie — can  learn 
everything  really  requisite  from  using  this  instrument.  I  am  aware 
that  Dr.  Dick,  Mr.  Teevan,1  and  other  eminent  surgeons  who  have 
paid  great  attention  to  gleet,  recommend  the  use  of  the  ball-staff, 
very  much  modified,  however,  from  the  form  originally  suggested 
by  Sir  Charles  Bell,  whose  invention  it  was ;  but  cogent  as  their  argu- 

1  British  Medical  Journal,  vol.  i.,  p.  494.     1869. 
4 


PATHOLOGY  AND  TREATMENT  OF  GLEET.        283 

ments  may  be,  I  must  venture  to  abide  by  the  position  laid  down,  and  I 
appeal  to  the  results  of  experience  in  support  of  it. 

Dr.  Otis  is  an  ardent  advocate  of  the  ball-staff.  He  prefers  one  with 
an  olive-shaped  end  of  metal,  and  a  soft  metal  shaft,  as  this  gives  greater 
firmness  than  the  flexible  shaft  of  Le  Roy  d'Etiolles,  and  is  easier  with- 
drawn than  a  ball  or  acorn-shaped  knob.  The  size  of  the  bulb  is  deter- 
mined by  that  of  the  urethra!  mouth,  which  it  must  fit  accurately.  The 
ball  is  pushed  home  to  the  bladder,  and  after  being  allowed  to  remain 
there  two  or  three  minutes,  is  slowly  withdrawn  ;  if  a  contraction,  even  not 
more  than  half  a  line  in  thickness,  exist,  its  whereabouts  will  be  indicated 
by  a  slight  clinging  or  want  of  suppleness.  He  couples  with  this  exposi- 
tion of  his  views  a  recommendation,  which  certainly  shows  great  faith  on 
his  part,  and  suggests  equally  great  compliance  on  that  of  his  patients.  I 
give  it  in  his  own  words.  "Should  this  proceeding,"  he  says,  "fail  in 
locating  a  stricture,  I  am  accustomed  to  slit  up  the  meatus  freely,  and 
repeat  the  operation  with  the  largest  bulb  that  will  enter  the  spongy  por- 
tion." A  further  modification  of  the  bulb  has  been  introduced,  in  which 
it  is  made  almost  triangular  with  the  broad  end  attached. 

My  impression  at  one  time  was  that  in  England  not  a  single  patient 
would  allow  a  surgeon  to  use  such  a  method,  excellent  as  it  might  promise 
to  be ;  I  have  had  good  reason  to  know  that  I  was  mistaken.  The  opera- 
tion has  been  repeatedly  performed  in  England,  as  far  as  I  can  make  out 
with  complete  failure  as  regards  the  gleet.  This,  too,  is  Mr.  Reginald 
Harrison's  experience.  "  In  several  instances,"  he  says,1  "  which  have  come 
under  my  notice,  the  performance  of  internal  urethrotomy,  as  recom- 
mended by  Dr.  Otis,  has  entirely  failed  to  remove  the  disease — namely  the 
gleet  for  which  it  was  undertaken. 

The  second  step  is,  having  made  out  the  size,  that  the  bougie  should 
be  properly  passed  twice  a  week.  By  properly,  I  mean  that  it  should  be 
gently  and  slowly  passed  quite  into  the  bladder,  and  that  it  should  never 
be  suffered  to  remain  in  the  urethra  more  than  two  or  three  minutes  at  the 
utmost ;  indeed  forty  or  fifty  seconds  is  generally  enough.  My  experience 
has  satisfied  me  that  to  pass  a  bougie  too  often,  or  to  let  it  remain  in  the 
passage  too  long,  is  a  mistake,  and  that  instead  of  hastening  the  cure,  it  is 
very  apt  to  retard  it,  by  setting  up  so  much  irritation  that  instead  of  the 
stricture  yielding  more  rapidly  it  becomes  more  contracted.  Too  much 
gentleness  can  never  be  exercised,  and  if  I  have  learned  one  thing  more 
than  another  from  experience,  it  is  that  when  the  stricture  is  very  tight, 
irritable,  and  resilient,  gentleness  will  get  through  it  more  frequently  and 
effectually  than  any  brusque  movement.  The  more  sensitive,  too,  a 
patient  is  to  pain,  the  more  is  this  treatment  adapted  to  his  case.  I  have 
repeatedly,  when  the  patient  had  suffered  so  much  from  the  use  of  a  metal- 


1  Lancet,  vol.  i.,  p.  760.     1880. 


284  ON    GONORRHOEA. 

lie  or  even  an  ordinary  gum-elastic  bougie  that  he  shrank  from  the  very 
idea  of  an  instrument,  guided  one  of  these  softened  bougies  through  with- 
out creating  more  than  the  most  trifling  uneasiness.  The  passing  of  the 
instrument  is  rendered  less  unpleasant  by  steeping  it  the  first  two  or  three 
times  in  hot  water.  Properly  employed  the  bougie  is  of  great  service  and 
I  have  much  faith  in  it.  I  have  not  had  the  extraordinary  success  with  it 
mentioned  by  M.  Montanier, '  who  saw  once  passing  a  bougie  cure  a  gleet 
which  had  lasted  six  years,  but  I  believe  it  to  be  an  excellent  remedy. 

I  have  repeatedly  been  asked,  both  by  surgeons  and  patients,  how  a 
bougie  acts  in  gleet,  and  therefore  hasten  to  give  the  only  explanation 
which  suggests  itself  to  me.  I  have  watched  the  effects  of  the  operation 
as  closely  as  I  could,  and  imagine  that  it  acts  much  like  a  blister  on  a 
small  scale  ;  that  is  to  say,  it  excites  an  afflux  of  vital  power  toward  a  part 
already  attracting  an  abnormal  amount,  and  that,  with  the  reattraction  of 
the  now  mobilized  vital  power  toward  the  seats  of  organic  life,  such  with- 
drawal being  occasioned  by  the  daily  wants  of  the  frame,  a  rebound  takes 
place,  which  lessens  the  accumulation  of  power  at  the  morbid  part.  This 
view  I  put  forward  many  years  ago  in  the  Medical  Times,  and,  if  it  be  not 
accepted,  I  have  no  other  to  offer. 

Certain  facts  lend  probability  to  it  both  as  regards  gleet  and  stricture, 
and  I  will  therefore  take  the  two  together.  Passing  a  bougie  in  either 
case  will,  at  first,  make  the  urethra  more  sensitive  than  it  was  immediately 
before,  so  that  some  change  at  any  rate  has  happened  in  the  state  of  the 
canal ;  but  if  the  employment  of  the  instrument  be  kept  up,  even  the  pre- 
vious sensitiveness  is  removed,  so  that  a  process  somewhat  of  the  nature 
that  I  have  pointed  out  must  have  taken  place.  This  is  still  more  noticeable 
when  an  injection  of  the  nitrate  has  been  employed,  as  then  the  canal  often 
swells  so  in  a  few  minutes,  that  a  bougie  which  would  have  gone  through 
easily  before  the  injection  cannot  be  passed  after  it ;  and  a  similar  change 
takes  place,  but  more  slowly,  after  the  solid  nitrate  has  been  applied. 
Both  cause,  in  addition,  heat  and  pain  at  the  time,  but  afterward  the  canal 
is  often  healthier  than  before.  Sometimes,  too,  a  gonorrhoea  will  super- 
vene upon  a  slight  and  recent  stricture  and  aggravate  it  for  the  time,  but 
with  the  decline  of  the  running  the  contraction  will  sometimes  also  yield, 
and  is  afterward  found  slighter  than  before.  Hunter's  theory  of  a  bougie 
setting  up  such  an  action  of  the  animal  powers  as  "  either  to  adapt  the 
parts  to  their  new  position  or  to  recede  by  ulceration,"  *  seems  to  me  crude 
in  respect  to  the  first  position,  as  though  the  idea  had  not  been  sufficiently 
worked  out  in  his  own  mind  ;  and  incorrect  as  regards  the  second,  seeing 
that  the  parts  do  not  recede  by  ulceration. 

Nitrate  of  Silver. — Should,  however,  the  progress  of  the  cure  not  cor- 
respond to  the  wishes  either  of  the  surgeon  or  the  patient,  should  the 

1  Gazette  des  Hdpitaux,  p.  286.     1869.  2Op.  citat.,  p.  118. 


PATHOLOGY  AND  TREATMENT  OF  GLEET.        285 

discharge  continue,  and  still  more,  should  it  be  aggravated  by  the  use  of 
the  instrument,  I  would  suggest  immediate  recourse  to  the  nitrate  of  silver, 
applied  as  described  at  page  220.  When  the  patient  prefers  the  nitrate  to 
the  bougie,  and  many  do  so,  I  would  apply  it  regularly  till  the  instrument 
slips,  without  any  force  being  used,  right  through  the  stricture.  When 
that  occurs  it  is  generally  not  necessary  to  do  much  more  with  either 
caustic  or  bougie.  A  few  extra  applications  of  either  can  do  no  harm,  but 
they  are  seldom  requisite.  Practically  the  stricture  is  cured  in  so  far  as  it 
admits  of  cure  at  all ;  and,  according  to  my  experience,  quite  as  effectually 
as  if  it  had  been  expanded  to  the  utmost  limits. 

To  show  how  freely  the  nitrate  may  be  applied,  with  impunity,  by 
means  of  the  instrument  I  have  described,  I  may  mention  that,  in  cases 
where  the  patient  was  about  to  leave  England  I  have  used  the  caustic  as 
often  as  six,  eight,  fourteen,  or  even  nineteen  days  in  almost  unbroken 
succession,  and  though  a  good  deal  of  suffering  was  often  caused,  no  other 
ill  effects  ensued  ;  the  patients  were  always  able  to  attend  to  all  that  was 
necessary  for  their  departure,  and  in  some  instances  I  know  that  they 
made  fair  and  even  good  recoveries.  Of  many  I,  of  course,  heard  no 
further,  but  no  instance  of  any  serious  results  has  come  under  my  notice, 
and  that  is  more  than  I  can  say  of  speedy  dilatation. 

In  one  case  I  used  it  three  or  four  times  a  week  for  upward  of  three 
months,  with  the  best  results.  The  patient  had  come  from  Jamaica,  prin- 
cipally to  be  treated  for  his  complaint.  The  written  account  which  he 
brought  from  the  surgeon  who  recommended  him  to  put  himself  under 
my  care,  and  who  shortly  after  followed  him  to  England,  was  that  he  had 
three  strictures ;  the  most  anterior  one  only  allowing  a  number  four  to 
pass,  while  the  finest  size  alone  could  be  got  through  the  second,  and  none 
through  the  third  ;  and  that  had  he  been  between  twelve  and  thirteen  years 
under  the  care  of  this  gentleman.  The  patient  was  in  rather  broken 
health,  and  had  on  each  knee  and  the  left  elbow  a  mass  of  gouty  deposit, 
somewhat  like  a  large  limpet  in  shape,  formed  of  thickish  flakes,  scattered 
irregularly  through  the  subcutaneous  and  dermoid  tissues.  The  nitrate 
was  after  a  time  or  two  applied  most  vigorously,  the  strictures,  the  two 
latter  being  apparently  one  continuous  narrowing,  yielded  i-apidly,  and  in 
the  presence  of  the  surgeon,  who  was  extremely  gratified  with  the  result, 
and  would,  I  feel  sure,  confirm  all  I  say,  at  the  conclusion  of  the  treatment 
I  passed  a  full-sized  bougie  into  the  bladder. 

Potassafusa. — The  late  Mr.  T.  Carr  Jackson  employed  caustic  for  strict- 
ure in  a  manner  which,  though  more  suited  to  the  cases  I  have  spoken  of 
as  beyond  my  province,  proved  so  very  successful  that  I  go  out  of  my  way 
to  notice  it,  as  it  might  be  a  valuable  resource  here.  He  used  the  potassa 
fusa,  and  applied  it  by  means  of  a  silver  caustic-holder,  shaped  like  a 
catheter  and  of  number  seven  gauge.  The  tip,  which  screws  off  and  on,  is 
hollowed,  and  pierced  with  a  hole  just  large  enough  to  let  a  bristle  pass 


286  ON    GONORRHXEA. 

through.  The  caustic  is  laid  in  the  hollow  of  the  tip,  and  when  this  is 
screwed  on,  the  point  of  the  stem  on  which  it  is  screwed  holds  the  potass 
against  the  hole  in  the  tip.  The  instalment,  oiled,  is  passed  down  the 
urethra  till  the  point  reaches  the  contraction,  and  then  the  salt,  melting, 
flows  out  through  the  hole  and  acts  on  the  stricture.  The  holder  is  armed 
with  a  piece  of  potass  about  the  size  of  a  number  six  shot.  Mr.  Jackson 
used  this  instrument  very  successfully  in  many  bad  cases,  and  especially 
in  one  of  traumatic  stricture,  where  it  was  impossible  to  get4  even  the 
smallest  catgut  through,  the  urine  passing  only  by  drops  ;  and  where,  after 
seven  applications,  the  potass,  even  under  these  unfavorable  circumstances, 
effected  such  a  steady  relaxation  that  a  number  two  catheter  could  be  in- 
troduced, and  in  three  weeks  more  a  number  ten. 

Blistering. — It  will  now  be  necessary  to  take  up  again  the  treatment  of 
this  class  of  cases  when  not  complicated  by  stricture,  and  in  these  I  would 
advise  that,  if  injections  do  not  within  a  very  short  time  produce  a  distinct 
lessening  of  the  discharge,  the  penis  should  be  blistered  without  delay, 
and  whatever  form  of  counter-irritant  the  surgeon  may  choose,  observation 
will  quickly  show  him  that  there  should  be  complete  vesication.  So  soon 
as  the  soreness  has  passed  off,  mild  injections  can  be  employed.  Should 
the  action  of  the  blister  not  correspond  to  the  expectations  entertained, 
the  use  of  the  bougie,  and  touching  the  posterior  part  of  the  urethra  gently 
with  the  nitrate  of  silver,  will  now,. assisted  by  a  mild  aperient  and  tonic, 
generally  effect  a  cure.  But  if  the  exigencies  of  the  case  seem  to  demand 
it,  I  never  hesitate  to  blister  again  and  again  till  I  have  gained  the  point  in 
view.  To  the  objection  that  others  have  not  succeeded  so  well  with  blis- 
tering in  gleet,  I  must  with  ah1  deference  reply  that  this  is  because  it  has 
not  been  properly  employed  and  properly  seconded.  In  many  cases  it 
must  be  thoroughly  done  or  it  had  better  be  left  undone,  and  it  should  be 
effectually  supplemented  by  the  use  of  the  bougie  or  nitrate,  or  both. 
Resorted  to  in  this  way  in  earnest,  it  will  rarely  fail  to  render  most  timely, 
often  invaluable,  assistance  ;  the  testimony  of  many  surgeons  who  have 
employed  it  at  my  recommendation  is  quite  to  this  effect,  and  from  all 
theoretical  objections  I  appeal  confidently  to  the  fruits  of  treatment.  A 
blister  is  one  of  the  most  powerful  remedies  that  can  be  employed  in  any 
case  that  is  not  complicated  with  stricture.  So  far  as  my  experience  goes, 
it  is,  when  properly  used,  the  most  efficacious  remedy  we  possess  in  many 
cases,  and  the  best  calculated  to  remove  that  painful  susceptible  state  of 
the  urethra,  often  remaining  after  gonorrhoea  treated  in  the  usual  way,  the 
tendency  to  catch  fresh  infection,  and  the  defective  expulsion  of  urine  and 
dribbling  after  making  water,  which  lead  so  many  patients  to  think 
they  have  stricture.  As  to  the  discomforts  of  blistering,  I  consider  them 
as  nothing  in  comparison  with  those  caused  by  gleet.  If  patients  com- 
plain of  such  trifling  drawbacks,  it  only  shows  how  inconsistent  and  un- 
grateful man  is.  They  must,  then,  really  expect  \o  be  cured  of  these 


PATHOLOGY  AND  TREATMENT  OF  GLEET.         287 

disorders  without  any  sacrifice  of  trouble  or  convenience.  If  they  had 
lived  a  century  ago,  they  would  have  been  only  too  glad  to  avail  them- 
selves of  such  a  remedy.  Among  the  advantages,  too,  of  blistering  is  the 
fact  that  it  generally  arrests,  or  cures  effectually,  that  unsatisfactory  state 
known  as  irritable  urethra.  Properly  aided  by  some  tonic  suited  to  the 
patient's  digestion,  and  mild  aperients,  it  will  remove  irritability  more 
rapidly  than  any  remedy  I  have  seen  tried  or  ever  heard  of. 

During  the  time,  however,  that  the  method  is  being  put  in  force  the 
patient  requires  no  particular  internal  treatment ;  it  is  as  weh1  to  keep  the 
bowels  open,  and  sometimes  a  sharp  dose  of  calomel  followed  by  a  black 
draught  acts  beneficially.  Now  and  then  it  will  happen  that  a  patient, 
who  is  being  treated  in  this  way,  has  to  endure  the  mortification  of  find- 
ing the  discharge  reappear  at  the  very  moment  he  thought  all  gone.  Thus 
on  the  third  day  there  may  be  no  running,  and  on  the  fourth  there  is  a 
good  deal ;  but  it  generally  subsides  as  rapidly  as  it  appeared  if  the  patient 
will  only  abstain  from  tampering  with  it. 

How  does  this  remedy  act  ?  By  counter-irritation,  will  perhaps  be  the 
answer.  But,  if  this  were  the  case,  why  should  there  be  increased  action 
in  the  urethra  for  a  few  days,  and  why  should  the  discharge  from  the  ure- 
thra begin  to  disappear  when  the  counter-irritant  surface  is  healing  up  ? 
I  lean  to  the  belief  that  the  action  is  purely  reflex,  and  that  the  explanation 
suggested  in  the  Laws  of  Life  is  the  one  which  will  hold  its  ground. 

Should  symptoms  point  to  the  posterior  part  of  the  urethra  as  the  seat 
of  the  discharge,  I  would  recommend  that  the  perineum  should  be  blis- 
tered. A  very  good  way  of  doing  this  is  to  apply  Bullin's  blistering  fluid  by 
means  of  a  camel's-hair  pencil.  It  should  be  laid  on  with  a  rather  dry 
brush,  so  that  none  of  the  fluid  trickles  down  and  excoriates  the  thighs  or 
scrotum,  and  a  space  the  size  of  the  palm  of  the  hand  should  be  painted 
over  with  it.  This  process  soon  raises  a  blister,  which  is  to  be  dressed 
like  the  others,  but,  of  course,  only  a  T  bandage  can  be  used.  This  may 
be  made  by  attaching  a  handkerchief  to  the  back  of  the  belt  of  a  suspen- 
sory bandage  (or  another  handkerchief  tied  round  the  waist),  bringing  it 
up  between  the  thighs,  and  fastening  it  to  the  belt  in  front.  A  pad, 
shaped  as  much  as  possible  like  the  roof  of  a  small  toyhouse,  is  fastened 
with  the  ridge  upward  to  the  part  next  the  blistered  surface,  and  on  this 
is  laid  the  lint  or  linen  with  the  ointment,  which  it  serves  to  retain  in  its 
place.  Friction  of  one  blistered  surface  against  another,  the  great  source 
of  discomfort,  is  thus  prevented.  The  patient,  unless  of  an  inventive  turn 
of  mind,  is  apt  to  fail  with  his  first  essay,  but  he  soon  learns  to  dress  a 
blister  deftly  enough.  A  bandage  adapted  to  this  purpose,  with  a  trian- 
gular moc-main  pad  and  elastic  belts,  is  made  for  my  patients  by  Walters 
&  Co.  It  answers  well  and  keeps  the  part  comfortable. 

Men  suffering  from  gleet  in  any  form  are  very  often  habitually  guilty 
of  one  piece  of  imprudence.  In  order  to  see  how  the  complaint  is  going 


288  ON    GOISTORRHCEA. 

on,  they  squeeze  the  penis  to  force  out  any  pus.  They  should  be  strictly 
warned  not  to  do  this.  I  have  many  times  had  reason  to  believe  that  this 
habit  had  been  instrumental  in  keeping  alive  the  discharge,  because  so  soon 
as  they  had  desisted  this  had  somewhat  diminished.  The  proper  plan  for 
ascertaining  whether  the  secretion  of  pus  is  lessening  or  not  is  to  make 
water  into  a  glass  vessel — an  old  tumbler  for  instance,  and  examine  the 
amount  of  shreds  in  the  urine. 

Diet  in  Gleet. — Patients  continually  ask  what  kind  of  diet  is  best  suited 
to  the  case,  and  especially  in  reference  to  the  form  now  under  notice.  I 
believe  the  answer  to  be,  simply,  that  a  plain,  light  but  good  diet  will  meet 
all  requirements  ;  that  in  every  form  of  disorder  known,  or  supposed,  to  be 
influenced  by  the  food,  it  is  safer  to  avoid  over-free  use  of  ascescent  arti- 
cles, and  those  which  are  hard  to  digest,  such  as  pickles,  pork,  and  shell- 
fish ;  and  that  the  best  kind  of  drink  is  some  light  red  wine.  The  late 
Mr.  Skey  was  very  fond  of  recommending  beer  in  this  stage  of  the  com- 
plaint. I  can  only  say  that,  while  I  never  saw  malt-liquor  in  any  shape 
do  the  least  good,  I  have  met  with  many  cases  where  it  certainly  seemed 
to  do  harm  ;  and  it  is  rather  a  puzzle  to  me  why,  if  it  possesses  any  cura- 
tive property,  it  does  not  cure  some  of  the  many  persons  who  take  it  daily 
while  suffering  from  gleet.  I  apprehend,  however,  that  most  of  those  who 
inquire  thoroughly  into  the  question  will  fail  to  find  any  virtue  in  beer  ; 
neither  indeed  wiU  they  in  red  wine  so  far  as  visible  curative  action  is  con- 
cerned ;  but  the  latter  possesses  the  great  advantage  that  it  never  does 
harm,  while  weak,  ansemic  people  frequently  grow  strong  and  make  'blood 
on  it.  With  respect  to  the  kind  to  be  recommended,  a  question  the  pa- 
tient is  almost  sure  to  put,  I  may  answer  that  I  have  tried  the  vintages  of 
France,  Spain,  Sicily,  Greece,  and  Hungary,  without  being  able  to  detect 
any  particular  superiority  in  one  over  the  other  ;  and  after  years  of  obser- 
vation have  only  been  able  to  conclude,  that  any  sound  unbrandied  wine 
of  the  claret  or  burgundy  class  will  serve  the  purpose. 

Complications  of  Gleet. — I  have  now  to  draw  upon  others  for  rules  of 
treatment  respecting  one  or  two  complications,  which  may  as  well  be 
looked  into  here,  inasmuch  as  they  apply  equally  whatever  form  of  gleet 
they  may  appear  with.  These  are — I.  A  granular  condition  of  the  urethra 
with  or  without  ulceration,  of  which  I  have  no  sort  of  knowledge,  having 
never  seen  reason  to  believe  that  I  had  such  a  state  of  matters  before  me. 
2.  Abnormal  sensitiveness  of  the  urethra,  described  by  Dr.  Otis,  and  seem- 
ingly a  more  persistent  form  of  the  symptom  already  spoken  of  as  irritable 
urethra,  and  for  the  cure  of  which  he  passes  a  stream  of  carbonic  acid 
through  the  channel  by  means  of  a  flexible  catheter.  3.  The  sinuses  men- 
tioned by  the  same  author,  which  he  treats  by  incision.  For  instance,  in 
the  case  already  described,  where  the  two  openings  were  outlets  of  this  na- 
ture, he  slit  them  up  so  as  to  l&y  the  two  into  one,  cauterized  the  ulcer  (!) 
in  the  floor  of  the  fossa  navicularis,  and  in  twenty  days  the  wound  was 


PATHOLOGY   AND    TREATMENT    OF    GLEET.  289 

cicatrized  and  the  discharge  had  ceased.  There  was  also  a  contraction  of 
the  urethra,  close  to  the  ulcer,  which  he  slit  up.  4.  The  follicular  gleet 
spoken  of  by  M.  Diday,  which  he  treats  with  the  actual  cautery,  wriggling 
a  knitting  needle  to  the  bottom  of  the  little  pouch,  and  then  heating  the 
needle. 

Along  with  these  may  be  taken  the  cases  of  gleet  depending  upon  en- 
gagement of  the  lacuna  magna,  for  which  also  incision  has  been  recom- 
mended. Dr.  Otis  says  that  Dr.  Benjamin  Phillips,  in  his  treatise  on 
"  Diseases  of  the  Urethra,"  relates  four  cases  of  this  complication,  in  which 
he  performed  the  operation  with  success.  I  have  sought  in  vain  for  this 
work,  of  which  Dr.  Otis  does  not  give  the  date,  or  the  pages  at  which  the 
histories  of  the  cases  are  to  be  found,  and  Dr.  Bumstead's  search  for  it  was 
equally  unsuccessful. '  I  was  under  the  impression  that  these  must  be  the 
cases  referred  to  by  him,2  but  he  kindly  pointed  out  to  me  that  he  quoted 
from  Dr.  Charles  Phillips,  of  Paris,  who  states  that  he  cured  four  cases  of 
obstinate  gleet  by  introducing  a  director  along  the  urethra,  and  then  slit- 
ting up  the  wall  of  the  follicle  with  a  narrow  bistoury.  There  is  a  well- 
known  book  by  Mr.  Benjamin  Phillips,  formerly  surgeon  to  Westminster 
Hospital,  but  the  title  of  it  is  "  On  the  Urethra,"  and  the  only  copy  of  it 
in  the  Library  of  the  College  of  Surgeons  does  not,  I  believe,  contain  any 
mention  of  such  treatment. 

Second  Class — Inveterate  Gonorrhoea. — In  every  case  of  this  kind,  what- 
ever may  have  been  the  previous  duration  of  the  disease,  I  can  see  no 
objection  to  its  being  treated  at  once  as  acute  gonorrhoea,  and  perhaps  a 
small  number  of  these  cases  may  be  cured — certainly  many  of  them  are 
somewhat  relieved.  Here  also,  if  at  the  end  of  thirty  days  no  improve- 
ment be  effected,  the  disease  will  in  most  cases  not  be  subdued  by  any 
amount  of  perseverance  in  the  use  of  such  remedies  ;  accordingly  at  the 
end  of  this  time  I  at  once  blister  the  penis  and  order  a  smart  purgative, 
treating  the  case  subsequently  as  in  the  preceding  class.  When  the  sur- 
geon has  removed  a  discharge  of  this  kind,  I  would  strongly  advise  con- 
tinuing the  use  of  the  bougie,  as  recommended  at  page  283,  once  or  twice 
a  week,  for  some  little  time  after.  The  urethra  is  not  always  restored  to  a 
healthy  state  with  the  cessation  of  the  discharge.  During  all  this  time  a 
tonic  and  aperient  ought  to  be  given. 

Dr.  Abrath,  medical  officer  to  the  hospital  for  foreign  seamen  at  Sun- 
derlaud,  communicated  to  the  Medical  Times  and  Gazette,3  the  history  of 
five  cases  which  I  think  belong  to  this  category.  The  disease  had  lasted 
from  fourteen  months  to  two  years,  and  had  defied  all  remedies.  He 
treated  the  patients  most  successfully  by  means  of  ice,  introduced  down 

1  Bumstead  and  Taylor :  The  Pathology  and  Treatment  of  Venereal  Diseases,  p. 
82.     1879.      • 

2  Ibid.,  pp.  90  and  98.     1861. 

3  Vol.  i.,  p.  385.     1870. 

19 


290  ON    GONORRHOEA. 

the  urethra  night  and  morning,  the  channel  being  previously  washed  out. 
Also  eight  cases  of  leucorrhoea,  accompanied  by  erosion  of  the  cervix  uteri, 
ulceration  of  the  cervix,  etc.,  cured  with  the  same  means  in  from  four  to 
six  weeks. 

Third  Class — Muco-purulent  Gleet. — Here  the  bougie  may  at  once  be 
passed,  however  confidently  the  patient  may  assert  that  the  opening  never 
was  any  larger,  and  that  he  makes  water  as  well  as  ever  he  did.  In  all 
these  cases  I  have  found  stricture,  with  one  exception,  in  which  the  patient 
had  a  small  fistulous  opening  behind  the  frsenum,  and  so  habitually  placed 
his  finger  there  to  stop  the  urine  that  he  never  thought  of  telling  me.  In 
this  variety  I  have  sometimes  succeeded  in  arresting  the  discharge,  and  the 
patient  has  come  back  months  after  with  stricture,  so  that  I  now  always 
resort  to  the  bougie  without  delay.  If  there  be  much  muco-purulent 
•discharge,  a  mild  injection  may  also  be  used  ;  but  where  there  is  only  suf- 
ficient to  glue  the  lips  of  the  urethra  together,  the  necessary  relief  will 
frequently  be  derived  from  injections  of  pure  water.  In  many  of  these 
patients  the  health  is  a  little  out  of  order,  principally,  I  think,  from  their 
having  taken  so  much  medicine.  Small  doses  of  quinine,  a  mild  aperient 
pill  once  or  twice  a  week,  and,  when  there  is  pain  in  making  water,  an 
ointment  containing  twenty  grains  of  Morson's  veratrine  to  an  ounce  of 
lard,  rubbed  below  the  urethra,  will  generally  effect  a  good  cure. 

Fourth  Class — Prostatic  Gleet. — Obvious  as  the  similitude  is  between  the 
two  subdivisions  of  this  variety,  there  is  a  marked  difference  as  to  the 
effects  of  treatment ;  for  while  the  simple  form  is  usually  got  rid  of  with 
little  trouble,  and  seldom,  if  ever,  shows  any  disposition  to  take  on  the 
character  of  urethral  inflammation ;  that  from  contagion  is  often,  even 
when  very  slight,  intensely  obstinate,  and  is  liable,  although  no  discharge 
may  be  habitually  present,  to  assume,  under  the  operations  of  very  slight 
excitement,  ah1  the  characteristics  of  gonorrhoea.  I  give  two  cases  illustrat- 
ing the  persistency  of  this  form.  Properly  speaking,  they  belong  perhaps 
rather  to  the  section  on  prognosis,  but  the  recital  of  them  would  have  en- 
cumbered that  part  of  the  work  too  much.  These  cases  will  also  exemplify 
the  difficulties  which  sometimes  beset  the  only  treatment  likely  to  be  of 
service  ;  namely,  injections,  nitrate  of  silver,  and  free  dilatation. 

T.  S ,  Esq.,  a  healthy  man,  who  had  lived  long  abroad,  consulted 

me  respecting  a  gleet  of  this  kind  which  he  had  had  quite  twenty  years ; 
indeed  he  added  that,  if  he  put  down  the  time  at  five-and-twenty  he  should 
be  nearer  the  mark  ;  but  as  to  the  twenty  years  he  was  certain,  because  he 
had,  for  quite  that  time,  been  out  of  England,  and  he  had  contracted  the 
disorder  before  he  went  abroad.  There  was  usually  very  little  discharge, 
often  nothing  more  than  a  few  shreds  passed  within  the  urine,  there  being 
at  such  times  no  secretion  visible  at  the  mouth  of  the  urethra,  and  no 
stains  on  the  linen.  Connection,  however,  especially  if  he  had  been  hunt- 
ing much,  of  which  he  was  extremely  fond,  often  developed  it  rapidly.  He 


PATHOLOGY  AND  TREATMENT  OF  GLEET.         291 

said  there  was  a  gouty  history  in  the  family,  but  that  he  had  not  suffered 
from  the  complaint.  The  idea,  that  the  disposition  of  the  gleet  to  relapse  so 
continually  was  due  to  latent  gout,  had  taken  possession  of  his  mind,  and 
certainly  it  did  seem  anomalous  that  a  man  of  healthy  build  and  healthy 
habits,  for  such  he  described  his  to  be,  should  suffer  so  long.  His  com- 
plaint had  followed  a  gonorrhoea,  cured  by  means  of  copaiba  and  injections 
of  acetate  of  lead  combined  with  sulphate  of  zinc.  The  gonorrhoea  ap- 
parently got  quite  well,  but  in  the  long  interval  between  its  disappearance 
and  his  consulting  me,  he  had  suffered  almost  innumerable  relapses  after 
connection  with  perfectly  healthy  women. 

He  came  occasionally  to  see  me  for  eleven  months.  Injections  were 
given,  but  not  often  ;  the  gum  bougie  was  passed  now  and  then.  Once 
gout  appeared,  but  in  a  very  mild  form.  I  prescribed  colchicum  for  it, 
but  the  patient  had  a  horror  of  this  drug,  and  lithia  was  substituted.  The 
shreds  in  the  urine  did  not  lessen  under  this  treatment.  At  the  end  of 
the  eleven  months,  he  all  at  once  made  his  appearance  with  a  running 
which  looked  like  veritable  gonorrhoea  ;  it  had  come  on,  he  said,  very  shortly 
after  intercourse  with  a  woman  whom  he  knew  very  well,  and  who,  he  was 
assured,  had  no  disease. 

After  connection,  he  drank  two  glasses  of  hollands  and  water,  and  fol- 
lowed this  up  with  some  hard  hunting.  He  returned  to  town  with  a  pro- 
fuse discharge. 

A  mild  injection  of  nitrate  of  silver  was  given.  This  was  done  about 
half-past  one  in  the  afternoon.  The  next  day  the  patient  reported  that,  by 
five  P.M.  the  discharge  had  become  watery,  and  so  plentiful  that  he  fancied 
he  must  have  burst  some  internal  organ.  It  did  not  drip,  he  said,  it  ran 
from  him,  and,  as  it  subsided,  gave  place  to  a  dirty  green,  thick,  somewhat 
abundant  discharge,  accompanied  by  redness  of  the  glans  ;  these  he  told 
me  were  the  symptoms  he  usually  had  in  his  relapses.  Hot  bathing,  prep- 
arations of  potass,  aperients  and  low  diet  steadily  subdued  these  symptoms, 
but  they  receded  very  slowly.  He  was  a  good  deal  plagued  with  erections, 
but  lupulin  and  camphor  removed  this  symptom.  The  oil  of  sandal-wood 
was  now  tried,  and  at  first  he  thought  it  did  him  good.  Then,  an  injection 
with  the  long  syringe  having  cleared  the  way,  the  nitrate  was  applied  twice 
to  the  urethra  ;  once  by  means  of  the  short  stylet  and  sheath  to  the  front 
half,  the  second  time  with  the  long  instrument  to  the  posterior  half  of  the 
canal.  This  brought  on  a  great  deal  of  discharge,  some  slight  bleeding, 
and  considerable  irritation  in  the  urethra,  after  which  decided  improve- 
ment set  in.  I  now  proposed  blistering,  to  be  followed  by  thorough  dila- 
tation, with  a  view  to  sweeping  away  the  last  dregs  of  the  disease,  but  the 
patient  left  London,  and  I  believe  England,  quite  suddenly,  and  I  did  not 
see  him  again. 

I  had  under  my  care  a  case  of  this  class,  complicated  by  congenital 
tightness  of  the  mouth  of  the  urethra  (which  also  opened  about  four  lines 


292  ON    GONORRHOEA. 

behind  and  below  the  natural  site),  number  eight  bougie  only  passing  with 
difficulty.  The  patient,  a  surgeon,  said  he  had  done  everything  for  the 
gleet  that  he  could  think  of,  but  without  avail,  the  disease  having  lasted 
nearly  thirteen  years.  The  application,  however,  of  the  solid  nitrate,  by- 
means  of  a  sheath  and  stylet  not  larger  than  a  number  seven  catheter,  soon 
produced  a  favorable  change,  and  I  was  flattering  myself  with  the  hopes 
of  a  complete  recovery,  when  the  patient  was  suddenly  called  to  a  distance 
and  kept  there.  He  afterward  wrote,  saying  that  he  was  in  much  the 
same  state  as  when  he  left,  and  I  may  add  that  he  told  me,  while  having 
the  nitrate  applied,  that  it  was  the  only  thing  which  ever  really  "  touched  '* 
the  disease. 

Fifth  Class — Pure  Mucous  Gleet. — This  variety  need  not  detain  us. 
But  for  the  anxiety  it  causes  the  patient,  I  should  say  the  best  treatment 
was  to  let  it  alone.  I  have  tried  various  astringent  injections,  among  others 
that  of  green  tea,  without  much  result.  M.  Montanier  says '  he  has  never 
seen  it  cured  by  anything,  but  what  is  sure  to  die  out  of  itself  does  not 
need  curing.  OccasionaUy  the  resins,  such  as  Chian  turpentine,  in 
doses  of  ten  grains,  or  the  inspissated  essence  of  spruce  fir  or  pine,  in 
the  same  dose,  twice  a  day,  are  of  some  avail  whenever  the  bladder  is 
involved. 

For  Gleet  of  Couvper's  Ducts,  Dr.  Bicordi  tries  the  solid  nitrate  of  silver, 
and  this  failing,  destroys,  or  at  least  cuts  through,  the  submucous  part  of 
their  outlets.  For  this  purpose  he  uses  a  canula  with  a  stylet.  The  canula 
is  solid  at  the  tip,  which  is  shaped  much  like  that  of  a  catheter.  About  a 
centimetre  and  a  half  from  the  extremity  of  the  tip,  there  is  a  horizontal 
slit  traversing  four-fifths  of  the  periphery,  and  through  this  slit,  a  very 
small  scimetar-shaped  blade  is  made  to  protrude  to  the  extent  of  three 
millimetres,  by  turning  the  mandril  This  blade  in  its  course  describes  an 
arc  of  a  circle,  and  is  rendered  immovable  by  the  pressure  of  a  screw,  so 
that  there  is  no  danger  of  its  protruding  when  the  instrument  is  moved 
about  in  the  canal  With  this  he  cuts  the  floor  of  the  urethra  transversely 
in  three  or  four  places,  about  a  centimetre  apart,  and  to  the  depth  of  two 
millimetres,  the  first  incision  being  a  centimetre  and  a  half  anterior  to  the 
bulb  and  the  others  in  front  of  it.  A.  gum  catheter  must  be  kept  in  the 
urethra  for  twenty-four  to  thirty-six  hours  after.  The  treatment  seems  to 
have  been  successful  in  two  cases,  one  of  them  rebellious  to  previous 
methods,  and  probably  in  a  third,  where,  however,  the  later  result  was  not 
ascertained. 

As  to  the  treatment  of  gleet  by  insufflation,  as  recommended  by  M. 
Mallez,"  and  later  by  Mr.  Wilders  ; 3  that  of  chronic  prostatic  gleet  by 
touching  the  prostatic  portion  of  the  urethra  with  dilute  solution  of  the 

'Op.  citat.,  p.  278. 

*  Union  Medicale,  nouvelle  serie,  tome  xxx. ,  p.  126. 

3  Lancet,  vol.  i.,  p.  802.     1873. 


PATHOLOGY  AND  TREATMENT  OF  GLEET.        293 

perchloride  of  iron  ;  of  the  method  practised  by  Dr.  Clemens, '  who  uses 
what  might  be  described  as  a  guttered  bougie,  the  depressions  holding 
salves  charged  with  tannin,  ergo  tin,  etc.,  and  kept  in  an  ice-safe  till  wanted, 
and  indeed  as  to  all  the  remedies  not  specifically  recommended,  I  have  no 
experience  to  offer.  Insufflation  appears  to  have  succeeded  in  the  hands 
of  both  the  gentlemen  spoken  of,  M.  Mallez  having  cured  some  cases  of 
long  standing.  The  instrument  which  he  employs  was  exhibited  by  M. 
Eicord  at  a  meeting  of  the  Imperial  Academy  of  Medicine,  and  looks  highly 
ingenious.  The  judicious  use  of  perchloride  of  iron  is  most  probably  quite 
safe  ;  over-free  employment  of  it  brought  on  death  in  a  case  related  by  M. 
Venot.2 

M.  Charles  Phillips  speaks 3  of  defective  erections  and  premature  emis- 
sions as  common  results  of  gleet ;  but  I  have  never  noticed  a  single  fact 
which  lent  any  countenance  to  such  an  opinion.  There  is  a  gap  between 
the  cause  and  effect.  M.  Phillips  should  have  said  that  gonorrhoea  is  fol- 
lowed by  gleet,  and  brings  on  nocturnal  emissions  or  aggravates  them  when 
present,  a  state  always  succeeded  in  time  by  the  symptoms  he  mentions. 
The  one  great  mischief  to  be  dreaded  from  gleet  is  stricture,  with  its  con- 
comitant evils. 

In  my  opinion  the  patient  should  never  be  pronounced  cured  of  gleet, 
till  the  urethra  has  been  some  little  time  in  a  healthy  state,  and  till  a 
bougie  will  pass  without  causing  any  particular  uneasiness,  or  bringing  on 
any  return  of  the  discharges.  It  is  not  always  easy  or  pleasant  to  answer 
the  patient's  questions  on  this  head,  but  so  long  as  there  is  any  unusual 
sensitiveness  of  the  urethra,  any  abnormal  redness  of  the  mucous  mem- 
brane, or  any  increase  in  the  natural  secretion  of  mucus  or  whitening  of  it, 
he  is  not  safe.  The  merest  speck  of  discharge  may,  after  years  of  quies- 
cence, ripen  into  mischief  or  convey  infection,  and  I  quite  concur  in  the 
censure  which  Mr.  Lee  passes  upon  Hunter's  dangerous  doctrine  about 
gleet  being  innocuous  ;  a  doctrine  upheld  again  not  very  long  since,  by 
M.  Charles  Dufour,4  as  also  practically  by  Noeggerath  and  those  who  sanc- 
tion his  views. 

B.  In  the  Female. — On  this  head  it  will  not  be  necessary  to  say  much, 
seeing  that  for  the  most  part  only  a  persevering  use  of  very  simple  means 
is  required.  When  the  patient  is  out  of  health  and  the  appetite  is  bad, 
dilute  nitro-hydrochloric  or  sulphuric  acid  should  be  given  in  some  bitter 
or  aromatic  infusion  such  as  calumba  or  snakeroot,  to  be  followed  by  quin- 
ine or  steel.  The  stiingy  plug  of  mucus  (page  145),  if  present,  should  be 
removed,  and  the  vagina  cauterized  twice  a  week.  I  have  never  yet  found 

1  Deutsche  Klinik,  S.  186.     1873. 

2  Union  Medicale,  tome  xi. ,  p.  5.     1857. 

3  Traite  des  Maladies  des  Voies  Urinaire,  p.  32.     1860. 

4  Union  Medicale,  nouvelle  serie,  tome  xi.,  p.  287. 


294  ON    GONORRHCEA. 

it  necessary  to  apply  the  nitrate  to  the  female  urethra.  Unless  the  dis- 
charge begins  to  abate  within  a  fortnight,  I  always  recommend  that  the 
groin  be  blistered ;  and  as  well  as  I  can  make  out,  these  means  suffice 
quite  as  effectually  for  the  removal  of  disease  in  any  uncomplicated  case  as 
the  most  elaborate  system.  The  patient  should  keep  to  the  diet  laid  down 
for  the  male,  take  as  little  exercise  as  possible,  and  abstain  sedulously  from 
connection.  In  her  case,  too,  the  cure  should  never  be  pronounced  com- 
plete till  she  has  been  free  from  discharge  quite  a  month. 


INDEX, 


ABORTIVE  treatment  of  gonorrhoea,  122 
Abrath,  Dr.,  his  treatment  of  inveterate 

gonorrhoea,  289 

Abscess,  gonorrhceal,  peri-nephritic,  232 
perineal,  225 
prostatic,  227 
Acidity  of  urine,  causes  of,  154 

of  urine,  power  of  alkalies  over,  158, 

159 

Acton,  Mr. ,  on  the  curative  power  of  in- 
jections in  gonorrhoea,  112 
Adams,  Mr. ,  his  treatment  of  gonorrhoeal 

ophthalmia,  264 
Adenitis,  gonorrhoeal,  254 
Albucazem  recommends  leaden  sounds  for 

stricture,  5 

Alexander,  Dr.,  case  of  gonorrhoeal  peri- 
nephritic  abscess  related  by,  232 
Alkalies,  action  of,  in  scalding,  82 
Alsaharavius,  evidence  of,  as  to  early  ex- 
istence of  gonorrhoea,  4 
Alteratives  in  gonorrhoea,  94 
Althaus,  Dr. ,  case  of  serious  nervous  symp- 
toms following  upon  gonorrhoea  related 
by,  44 
Alvarez,  Dr.  Julian,  his  treatment  of  or- 

chitis,  195 
Amputation  of  part  of  penis  in  paraphi- 

mosis,  204 

Animal  chemistry,  bearing  of,  on  pathol- 
ogy of  scalding,  153 
Anodynes,  action  of,  in  scalding,  156 
Antiphlogistic  treatment  of  gonorrhoea,  77, 

88 

treatment  of  orchitis,  189 
Aperients  in  gonorrhoea,  91 

table  of  cases  treated  with,  91 
Applications,  cold,  in  gonorrhoea,  95 
direct,  in  gonorrhoea,  100 
external,  in  gonorrhoea,  95 
hot,  in  gonorrhoea,  96 
sedative,  in  gonorrhoea,  95,  98 
Aquo-capsulitis,  gonorrhoeal,  267 
Arcalanus,  John,  describes  gonorrhceal  cys- 
titis, 5 

Ascarides  as  a  cause  of  gonorrhoea,  99 
Ashwell,  Dr.,  on  seat  of  gonorrhoea  in  the 

female,  38 

Assadorian,   Dr.,  on  the  treatment  of  or- 
chitis with  ether,  195 


Astruc's  treatment  of  gonorrhoea,  63 
Atkinson,  Dr. ,  on  sandal-wood  oil  in  gonor- 
rhoea, 84 
Atrophy  of  parts  attacked  by  gonorrhceal 

arthritis.  239 
of  parts  attacked  by  gonorrhoeal  syno- 

vitis,  243 
of  testicle   from   puncture  of  tunica 

albuginea,  193 
Aubry,  M.,  on  effect  of  puncture  of  tunica 

albuginea  on  orchitis,  193 
Auspitz,  Herr,  his  researches  with  the  en- 

doscope,  27i> 

on  specific  virus  of  gonorrhoea,  15 
Avicenna,  evidence  of,  as  to   early  exist- 
ence of  gonorrhoea,  4,  6 

BADER,  MR.  ,  his  treatment  of  gouorrhoeal 

ophthalmia,  204 
Balanitis  as  a  cause  of  orchitis,  172 

occurring   along  with   phimosis    and 

stricture,  222 
treatment  of,  222 
Bantock,  Dr.,  on  Noeggerath's  theory  of 

gonorrhoeal  infection,  44 
Barker,  Dr.  Fordyce,  on  a  particular  dis- 
ease of  the  interior  of  the  womb,  16 
Barnes.  Dr.  R. ,  on  the  seat  of  gonorrhoea 

in  the  female,  38 
Bath,  cold  hip,  in  gonorrhoea  in  the  female, 

149 

hot,  in  gonorrhoea,  96 
hot,  in  scalding,  161.  162 
its  power   of   developing  gonorrhoea 

questioned,  154 
Bathing,  hot,  in  gonorrhoea,  98 
Baudin,  M.,  case  of  gonorrhceal  endocar- 
ditis related  by,  250 
Beale,  Dr  ,  on  cause  of  acidity  of  urine, 

154 

alkalinity  of  urine  after  meals,  155 
Becquerel.  M.,  on  state  of  urine  in  gonor- 
rhoea, 154 

Bell,  Sir  Charles,  mode  of  injecting  prac- 
tised by,  130 

on  the  pathology  of  chordee,  162 
Benedetti  possibly  acquainted  with  gonor- 
rhoea. 8 

Beneke,  Herr,  on  alkalinity  of  urine  after 
meals,  156 


296 


INDEX. 


Benzoate  of  soda  in  gonorrhceal  ophthal- 
mia, 265 
Beroaldus,  probable  mention  of  premature 

emission  by,  8 

Bethencourt,  James,  on  pathology  of  gon- 
orrhoea, 10 
Bird.  Dr.  Golding,  on  cause  of  acidity  of 

urine,  154 
Black,  Dr.  John,  on  use  of  suppositories 

in  vaginal  gonorrhoea,  144 
Bladder,  excessive  irritability  of,  222 
inflammation  of,  221 
irritable,  169 

Bleeding  as  a  remedy  in  gonorrhoea,  88 
as  a  remedy  in  orchitis,  110 
as  a  remedy  from  urethra,  strong  ten- 
dency to,  169 

Blister,  mode  of  applying,  139 
Blistering  in  acute  gonorrhoea,  137 

in    chronic  gonorrhoea    (See    Gleet), 

286 

in  orchitis,  200 

Bond,  Mr.,  on  mode  in  which  gonorrhoeal 
rheumatism  is  called  into  activity, 
255 

proportion  of  gonorrhoea  patients  at- 
tacked by  gonorrhoeal  rheumatism, 
242 
Bonnafont,  M. ,  on   treatment  of  orchitis 

with  collodion,  196,  197 
Bonniere,  M.,  on  the  seat  of  gonorrhoea  in 

the  female,  39 
on  the  seat  of  gonorrhoea  in  the  male, 

35 
Bougie,  method  of  passing,  283 

mode  of  action  of,  in  gleet,  284 
passing  of,  as  a  cause  of  gonorrhoea. 

24 

suggested  kind  of,  282 
Bougies,  soluble,  in  treatment  of  gonor- 
rhoea, 118 

Brandes,  M. ,  cases  of  gonorrhoeal  rheuma- 
tism related  by,  247 
on  mention  of  gonorrhoeal  rheumatism 

by  Monteggia,  235 
Brodie,  Sir  Benjamin,  on  cause  of  acidity 

of  urine,  154 
on  iodide  of  potassium  in  enlarged 

prostate.  227 

on  non-existence  of  gonorrhoeal  rheu- 
matism, 236 
on  relaxing  action  of  warm  water  on 

stricture,  99 
on  treatment  of  acute  inflammation  of 

bladder,  224 

.on  treatment  of  inflamed  prostate,  228  \ 
recognition    of    obstinate    nature    of ' 

gonorrhoeal  rheumatism  by,  235 
Bruck,   Dr.,  on  treatment  of  gonorrhoea 

with  corrosive  sublimate,  95 
Bubo,  sympathetic,  169 
Bumstead,  Dr.  J.    Freeman,  mode  of  in- 
jecting recommended  by,  129 
on  chances  of  aboitive  treatment  in  | 
gonorrhoea,  124 


Bumstead,   Dr.  J.    Freeman,   on   copaiba 

in  acute  stage  of  gonorrhoea.  77 
on  impossibility  of  injecting  bladder 

with  short  syringe,  131 
on  pathology  of  chordee.  165 
on  purgatives  in  gonorrhoea,  89 
on  repeated  connection  as  a  source  of 
gonorrhoea  in  the  female,  27 


CAMPBELL,  MR.  MACFIE,  on  average  dura- 
tion of  gonorrhoea  under  treatment,  71 
Camphor,  value  of,  in  chordee,  167 
Carmichael,  Richard,  not  an  advocate  for 

strong  nitrate  of  silver  injections,  123 
Castelnau,  M.,  011  disposition  of  orchitis  to 

become  chronic.  202 
statistics  of  orchitis  given  by,  187 
Cataneus,  James,  acquainted  with  gonor- 
rhoea, 7 
Caustic -holder,  Lallemand's,  objections  to, 

136 

recommended  in  preference  to  Lalle- 
mand's, 136,  218 
Caustic  plug  in  gonorrhoea,  134 
Cauterization  of  the  urethra.  136 
Celsus,  supposed   mention   of  gonorrhoea 

and  orchitis  by,  2 

Cervix  uteri,  treatment  of  gouorrhoeal  af- 
fection of  canal  of,  145 
Chabalier,  M. ,  on  the  antiquity  of  gonor- 
rhoea, 1 
Chambers,   Dr.    T.   K. ,  on  the  expectant 

treatment  of  gonorrhoea,  68 
on  the  prognosis  of  gonorrhoea,  40 
Change  of  injections,  necessity  for,  127 
Charteris,  Dr.,  cases  of  gonorihceal  pyaemia 

reported  by,  253 

on  post-mortem   appearances  in  gon- 
orrhoea, 35 
Cheyne,  Mr.  Watson,  on  antiseptic  soluble 

bougies  in  gonorrhoea,  119 
on  the  presence  of  micrococci  in  gon- 
orrhoeal pus,  48 
Chloride  of  zinc  in  gonorrhoea  (See  Zinc), 

113 

Chloroform  injections,  103 
Chordee,  pathology  of,  162 
prognosis  of,  165 
proposed  treatment  of,  167 
results  of,  165 

treatment  of,  usually  adopted,  166 
Cicero    quoted    by   M.    Chabalier   as  ac- 
quainted with  gonorrhoea,  3 
Cockburn  on  the  extension  of  gonorrhoeal 

inflammation  backwards,  34 
on  the  treatment  of  gonorrhoea,  62 
Cold  as  a  cause  of  orchitis,  174 

an  exciting  cause  of  gonorrhoeal  rheu- 
matism. 238 

Cold  water  injections,  104,  280 
Colles,  Mr. ,  on  the  extension  of  gonorrhoeal 

inflammation  backwards,  35 
Complications  of  gleet,  288 
of  gonorrhoea  in  men,  153 


INDEX. 


297 


Complications  of  gonorrhoea  which  do  not 

interfere  with  treatment,  153 
of  gonorrhoea   which    interfere   with 

treatment,  207 
of  gonorrhoea  in  the  female,  treatment 

of,  140 

of.gonorrhoea,  search  for,  140 
Connection  as  a  source  of  gonorrhoea,  13 
Constantino  of    Carthage,    description   of 

gonorrhoea  by,  6 
Cooke,  Mr.  Weeden.  on  action  of  alkalies  in 

scalding,  158 

on  consumption  of  copaiba,  74 
Cooper,    Sir  Astley,   gonorrhoeal  rheumat- 
ism described  by,    235 
mode  of   injecting  recommended  by, 

130 

on  extension  of  gonorrhoeal  inflamma- 
tion along  the  urethra,  34,  171 
on  the  treatment  of  gonorrhoea,  65 
Coote,  Mr.  Holmes,  case  of  rheumatism  of 

eyeball  related  by,  267 
on  results  of  orchitis,  188 
Copaiba  in  acute  stage  of  gonorrhoea,  77 
in  gonorrhoea,  73 
dose  and  mode  of  giving.  77 
percentage  of  volatile  oil  in,  79 
serious  results  from  use  of,  73 
table  of  cases  treated  with,  75 
Corpora  cavernosa,  gonorrhoeal  inflamma- 
tion of,  206 
Corpus  sponqiosum,  gonorrhoeal  inflamma- 

tiou  of,  2QQ 

Cowper's  glands,  gleet  of  ducts  of,  276 
Coxwell,    Mr.    Grinfield,    kind   of  syringe 

recommended  by,  129 
Critchett,  Mr.  Geo. ,  successful  treatment  of 
a  case  of  gonorrhoeal  ophthmalia  by,  265 
Cruize,  Dr.  Francis,  on  distinction  between 

two  kinds  of  gonorrhoea,  25 
on  extension  of  gonorrhoea  backwards, 

34 
Cubebs  in  gonorrhoea,  80 

and  copaiba  combined  in  gonorrhoea, 

80 

Curling,  Mr.,  employs  ice  in  orchitis,  195 
on  absence  of  spermatozoa  in  semen 

after  double  orchitis,  188 
on  non-arrest  of  the  discharge  in  or- 
chitis, 200 

DAVIES-COLLEY,  MR.  ,  case  of  gonorrhoeal 
pericarditis  related  by,  250 

cases  of  gonorrhoeal  (?)  endocarditis, 
related  by,  250 

on  cause  of  great  oedema  of  soft  parts 
in  gonorrhoeal  rheumatism.  238 

on  frequency  of  gonorrhoeal  rheuma- 
tism in  women.  ','46 

on  pathological  changes  in  gonorrhoeal 

arthritis,  257 

Death  from  gonorrhoeal  endocarditis,  247, 
249 

from  gonorrhoeal  inflammation  of  cav- 
ernous bodies,  206 


Death  from  gonorrhceal  orchitis,  187 
from  gonorrhceal  peritonitis,  230 
from  gonorrhceal  prostatic  abscess, 

227 

from  gonorrhoeal  pyaemia,  253 
from  gonorrhceal  (?)  pyelitis,  233 
Debeny,  M.,  advocates  strong  injections  of 

nitrate  of  silver,  123 
Deferentitis,    case   of,   mentioned  by   M. 

Gosselin,  195 

Demarquay.  M. ,  cases  of  wasting  of  testi- 
cle from  puncture  in  orchitis,  seen  by, 
190 
De  Meric,    Mr.,    on   acute   ovaritis    from 

gonorrhoea,  146 
injections  of  trisnitrate  of  bismuth  in 

gonorrhoea,  102 

Demulcents,  action  of,  in  scalding,  157 
Dentition  as  a  cause  of  gonorrhoea,  24,  25 
Desnos,  M,,  cases  of  gonorrhoeal  cardiac 

affection,  related  by,  248,  249 
his  unfavorable  experience  of  salycin 

in  gonorrhoeal  rheumatism,  258 
Desormeaux,   M.,  on  the  changes  seen  in 

the  urethra  in  gonorrhoea,  273 
Despres,    M. ,    on   pathology  of  relapsing 

orchitis,  187 
Diday,  M.,  his  mode  of  injecting,  112 

on  the  genesis  of  gonorrhoea  in   the 

male,  24 
on  hot   bath   as  a  remedy  in  gonpr- 

rhcea,  97 

on  value  of  ice  in  orchitis.  195 
on  value  of  sandal-wood  oil  in  gonor- 
rhoea, 85 
Diet  in  gleet,  288 

in  gonorrhoea,  150 

Discharge,  gonorrhceal,  arrest  of,  by  or- 
chitis, 186 
gouorrhceal,    method    of    preventing 

from  staining  linen,  131 
gonorrhoeal,  pathological  significance 

of,  27,  29,  43 

gonorrhoeal,  restoration  of,  as  a  rem- 
edy in  orchitis,  199 
gonorrhceal,    urethral,    from    leucor- 

rhcea,  milder  nature  of,  16 
gonorrhceal,  mechanical  means,  milder 

nature  of,  24 
Diuretics,  action  of,  in  gonorrhoea,  94 

action  of,  in  scalding,  157 
Dor,  M. ,  case  of  successful  treatment  of 
gonorrhceal     ophthalmia    reported    by, 
265 

Dreadnought   Hospital,  results  of  gonor- 
rhoeal rheumatism  seen  at,  258 
Dron.  M.,  serious  results  of  a  case  of  chordee 

reported  by,  165 
Dufour,  M.   Charles,  on  innocuous  nature 

of  gleet,  293 

Duncan,  Dr.   Mathews,  on  gonorrhoeal  af- 
fection of  Cowper's  glands  in  female,  148 
Duplay  and  Rrun,  MM.,  on  frequent  oc- 
currence of  gonorrhoeal  rheumatism  in. 
women,  247 


298 


INDEX. 


Duplay  and  Brun,   MM.,   on  rapid  disor- 
ganization of  joint  tissues  in  gonorrhceal 
arthritis,  257 
Dupouy,  M. ,  on.  kava-kava  as  a  remedy  in 

gonorrhoea,  81 

Durham.  Mr. ,  kind  of  syringe  recommend- 
ed by,  129 

on  influence  of  diet  on  urine,  153 
Durkee,  Dr.  Silas,  on  the  abortive  treat- 
ment of  gonorrhoea,  124 
on  the  employment  of  large  doses  of 
copaiba  in  acute   stages  of  gonor- 
rhoea, 77 
on  the  genesis  of  gonorrhoea  by  leucor- 

rhoea,  15 

on  purgatives  in  gonorrhoea,  90 
on  the  significance  of  pus-cells  in  dis- 
charge from  male  urethra,  29 
on  the  treatment  of  phimosis,  203 
Duverney's  glands,    gonorrhoeal   affection 

of,  148 
Edinburgh  Medical  and  Surgical  Journal, 

table  of  cases  of  gonorrhoea  from,  71 
Egan.    Dr.,   on   extension   of    gonorrhoeal 
action  backward  in  male  urethra,  35 
on  seat  of  gonorrhoea  in  the  female,  38 
Electricity,    atmospheric,    as   a  cause    of 

orchitis,  186 

Elliotson,  Dr.,  on  non-existence  of  gonor- 
rhoeal rheumatism,  236 
Endocarditis,  gonorrhceal,  247 
Endoscope,    the,    as   an  aid  to  diagnosis, 

272 
Epididymis,  principally  affected  in  orchitis, 

172 

Erectile   tissue  of  vagina,  gonorrhoeal  in- 
flammation of,  149 
Eric!. sen,  Mr.,  on  pathology  of  gonorrhoeal 

rheumatism,  257 
Erigeron  oil  as  a   remedy  in  gonorrhoea, 

87 
Errors   of   diet   as  a  cause  of  gonorrhoea, 

24 

Ether,  employment  of,  in  orchitis,  195, 199 
Expectant  treatment  of  gonorrhoea,  68 
Eye,  gonorrhoeal  affections  of,  262 
Eyeball,  gonorrhoeal  rheumatism  of,  267 
gonorrhoeal  rheumatism  of,  pathology 

of,  267 
gonorrhoeal  rheumatism  of,  prognosis 

of,  267 

gonorrhoeal  rheumatism  of,  treatment 
of,  267 

FAINTING  from  the  use  of  injections,  strong 
tendency  to,  as  a  complication  of  gonor- 
rhoea, 207 

Faucon,  M.,  on  sub -peritoneal  inflamma- 
tion from  gonorrhoea,  230 
Female,  genesis  of  gonorrhoea  in,  26 

period  of  incubation  of  gonorrhoea  in, 

39 

seat  of  gonorrhoea  in,  38 
treatment  of  gleet  in,  293 
treatment  of  gonorrhoea  in,  142 


Fereol,  M.,  case  of  glandular  inflammation 
complicating    gonorrhoeal    rheuma- 
tism related  by,  254 
on  concurrence  of  gonorrhoeal  rheuma- 
tism with  mild   form  of  gonorrhoea 
255 
views  of,  as  to  existence  of  gonorrhceal 

lues,  40 

Foot,  Jesse,  on  injurious  effects  of  allow- 
ing gonorrhoea  to   run  its  course,  70 
on  the  treatment  of  gonorrhoea,  64 
Form  for  calculating   action  of  remedies, 

96 
Fourestie,  M.,  on  different  nature  of  early 

and  late  gonorrhoeal  rheumatism,  255 
Fournier,  M.,  account    of  aquo-capsulitis 

by,  267 
account  of  gonorrhoeal  rheumatism  by, 

239 

account  of  gonorrhoeal  sciatica  by,  244 
on  cessation  of  pain  in   sphacelus  of 

testicle,  188 
on  communication  of  gonorrhoea  by  a 

•woman  not  infected,  23 
on  distinction  between  urethritia  and 
gonorrhoea  as  causes  of  gonorrhoea! 
rheumatism,  237 
on  proportion  of  gonorrhceal  synovitis 

to  gonorrhceal  rheumatism,  242 
on  treatment  of  true  orchitis,  198 
on  venereal  excess  as  a  cause  of 

gonorrhoea,  24 
France,  Mr.,  his  treatment  of  gonorrhceal 

ophthalmia,  264 

Freezing  the  testicle  as  a  remedy  in  orchi- 
tis, 195 
Fungus,  a,  origin  of  gonorrhoea  from,  45 

GARIOPONTFS     of      Salernum     describes 

gonorrhoeal  cystitis,  5 

Gaussail,  M.,  account  of  post-mortem  ap- 
pearances in  orchitis  by,  173 
Gay,  Mr.,  his  treatment  of  orchitis,  196 
Genesis  of  gonorrhoea  in  the  female.  26 

of  gonorrhoea  in  the  male.  12 
Gleet  as  a  source  of  gonorrhoea  in  the  fe- 
male, 28 

as  a  source  of  gonorrhoea  in  the  male, 
20 

complications  of,  288 

divisions  of,  269 

employment  of  blistering  in,  286 

employment  of  bougie  in,  281 

employment  of  caustic  in,  284 

muco-purulent,  270 

muco-purulent,  treatment  of,  277 

of  Cowper's  ducts.  276 

of  Cowper's' ducts,  treatment  of,  292 

pathology  of,  269 

prognosis  of,  277 

prostafcic,  270 

prostatic,  treatment  of,  290 

pure  mucous,  271 

pure  mucous,  treatment  of,  292 

treatment  of,  in  the  female,  293 


INDEX. 


299 


Gleet,  treatment  of,  in  the  male,  277 

treatment  of  complications  of,  288 
Glycero-tannin  rods,  120 
Gonorrhoea,  a  critical  flow,  10 

abortive  treatment  of.  122 

as  a  cause  of  stricture,  70 

complications  of.   (See  Complications. ) 

declining,  infectious  power  of,  30 

expectant  treatment  of,  68 

genesis  of,  in  the  female,  26 

genesis  of,  in  the  male,  12 

great  variety  of  remedies  for,  54 

history  of,  1 

history  of,  treatment  of,  57 

homoeopathic  treatment  of,  72 

incipient,  infectious  power  of,  30 

infection  of  system  by,  40 

infectious  power  of,  20 

in  the  female  as  a  cause  of  gonorrhoea 
in  the  male,  1 2 

in  the  male  as  a  cause  of  gonorrhoea 
in  the  female,  28 

inveterate,  269 

inveterate,  treatment  of,  289 

in  woman,  treatment  of,  142 

latent.  43 

little  alteration  in  treatment  of,  dur- 
ing last  century  or  two,  58 

milder   nature  of,  in  subsequent   at- 
tacks, 39 

of  long  standing,  269 

of  long  standing,  treatment  of,  280 

ordinary  treatment  of,  124 

pathology  of,  12 

present  treatment  of,  73 

produced  generally  by  connection  with 
an  infected  person,  17 

prognosis  of,  40 

proposed  treatment  of,  in  acute  cases, 
122 

proposed    treatment    of,    in    chronic 
cases,  277 

rarity  of,  in  earlier  days,  11 

results  of,  40 

seat  of,  in  the  female,  38 

seat  of,  in  the  male,  32 

specific  nature  of,  18 

term  of  incubation  of,  37,  39 

treatment  of,  54 

varying  duration  of.  49 
Gonorrhoeal    action,    extension  of,    back- 
wards. 33 

adenitis,  2.14 

affections  of  the  eye,  262 

endocarditis  and  pericarditis,  247 

meningitis,  251 

myelitis,  252 

ophthalmia  (See  Ophthalmia),  262 

peri-nephritic  abscess,  232 

peritonitis.  229 

pyaemia,  2r>3 

rheumatism  (See  Rheumatism),  234 

sciatica,  244 

synovitis,  242 
Gonorrhoeal  (?)  hepatitis,  252 


Gonorrhoeal  (?)  pleuritis,  234 

(?)  pyelitis  and  nephritis,  233 
(?)  nephritis,  253 
Good,  Dr.  Mason,  on  amputation  of  part 

of  penis  in  paraphimosis,  204 
Gordon,  Bernard,  evidence  of,  as  to  exist- 
ence of  gonorrhoea,  5,  7 
Gosselin,  M.,  case  of   deferentitis  related 

by,  202 

gonorrhceal  peritonitis  related  by,  229 
on  inflammation  of  vaginal  tunic  in 

orchitis,  172 
on  mode  in  which  gonorrhoea  in  the 

female  escapes  detection,  20 
on  the  prognosis  of  gonorrhoeal  rheu- 
matism, 257 
Graromer,  Dr.,  his  treatment  of  orchitis, 

195 

Greenhow,  Dr.,  case  of  gonorrhceal  (?)  pye- 
litis and  nephritis  mentioned  by,  233 
Guerin,  M. ,  on  the  form  of  discharge  which 

precedes  gonorrhoeul  rheumatism,  255 
Guerin  and  Pidoux,  MM.,  belief  of,  in  ex- 
istence of  a  gonorrhceal  lues,  40 
Gurgun  (wood-oil)  in  gonorrhoea,  87 
Guy  de  Chauliac,  evidence  of  his  knowl- 
edge of  gonorrhoea,  5 

HAGEMANN  on  the  seat  of  gonorrhoea  in 

the  female,  38 
Haby  Abbas,    mention   of    symptoms    of 

gonorrhoea  by,  4 

Hancock,  Mr.,  discovery  by,  of  prolonga- 
tion of  muscular  coat  of  bladder, 
154 

his  treatment  of  gonorrhceal  ophthal- 
mia, 264 

Hardy,  M. ,  case  of  failure  with  salycilate 
of  soda  in  gonorrhoeal  rheumatism 
related  by,  258 
gonorrhoeal  rheumatism    complicated 

with  nephritis  related  by,  253 
metastasis  in  gonorrhceal  rheumatism 

related  by,  255 
prognosis  of.  257 
Harley,  Dr.,  on  cause  of  acidity  of  urine, 

154 

on  alkalinity  of  urine  after  meals,  155 
Harrison,  Mr.  Reginald,  on  Dr.  Otis's  treat- 
ment of  stricture,  283 
recommends  cold-water  injections  in 

gleet,  281 
Hassall,  Dr. ,  on  cause  of  acidity  of  urine, 

154 
Healthy  state  of  organs  in  the  female  as  a 

source  of  gonorrhoea  in  the  male,  23 
Heat  and  cold,  therapeutic  action  of,  99 
Henderson.  Dr.  Thomas,  on  the  use  of  gur- 

gun  in  gonorrhoea,  87 
on  sandal-wood  oil  in  gonorrhoea,  84 
Hensler  on  absence  of  gonorrhoea  during 

first  period  of  syphilis,  7 
on    conflicting  nature  of    testimony 

about  gonorrhoea,  6 
Hepatitis,  gonorrhoeal  (?),  252 


300 


INDEX. 


Herodotus,  disease  of   the  Scythians  de- 
scribed by,  2 
Hervieux,  M.,  case  of  gonorrhoeal  cardiac 

affection  related  by,  250 
endocarditis  related  by,  247 
Hewitt,   Dr.  Graily,  on  the  seat  of  gonor- 
rhoea in  the  female,  38 
Hill,  Mr.  Berkeley,  on  the   antiquity  of 

gonorrhoea,  1 

on  frequent  occurrence  of  purulent  dis- 
charge from  the  womb  among  pros- 
titutes. 22 

on  permanganate  of  potass  as  an  injec- 
tion in  gonorrhoea,  102 
Hiller,  Dr.  A.,  on  transmission  of  uvethral 

discharge  from  male  to  female,  32 
Hip-bath,  hot,  in  gonorrhoea  in  the  female, 

142 
Hippocrates,  forms  of  leucorrhoea  described 

by,  2 
Hippuric   acid  as  a  factor  in  acidity  of 

urine,  155 
History  of  gonorrhoea,  1 

of  gonorrhoeal  rheumatism,  234 
Holmes,    Mr.    Timothy,    on   puncture  of 

tunica  albuginea  in  orchitis,  191 
Home,  Sir  Everard,   cases  of  gonorrhoeal 

sciatica  related  by,  244 
Homoeopathic  treatment  of  gonorrhoea,  72 
Howard,  Dr.,  on  site  of  lingering  gonor- 
rhoea in  the  female,  21 
Howard,  Mr.,  on  connection  between  in- 
veteracy and  diathesis,  49 
on  treatment  of  gonorrhoea,  64 
Huguier,   M.,  on  gonorrhoeal  affection  of 

vulvo-vaginal  glands.  148 
Hunter,  mention  of  gonorrhoeal  rheuma- 
tism by,  235 
mention   of  peritoneal   inflammation 

from  gonorrhoea  by,  229 
on  incubation  of  gonorrhoea,  38 
on  milder    nature   of    gonorrhoea  in 

subsequent  attacks,  39 
on  origin  of  stricture  from  gonorrhoea, 

70 
on  post-mortem  state   of  urethra  in 

gonorrhoea,  35 

on  the  pathology  of  chordee,  163 
on  the  specific  seat  of  gonorrhoea.  34 
on  the  treatment  of  gonorrhoea,  63 
on  the  way  in  which  a  bougie  acts  in 

stricture,  284 
Hypodermic    injections    in    endometritis 

following  on  gonorrhoea,  147 
injections  in  gonorrhoeal  rheumatism, 

261 
Hyoscyamus  in  scalding,  156 

ICE,  employment  of,  in  treatment  of  in- 
veterate gonorrhoea,  290 
employment  of,  in  orchitis,  195 
Incubation  of  gonorrhoea,  37,  39 
Infection  of  gonorrhoea,  point  from  which 

it  starts  in  the  male,  32 
Inhalation  as  a  remedy  in  gonorrhoea,  82 


Injections,  100 

as  a  cause  of  orchitis  and  stricture, 

105 

great  variety  of,  100 
in  gonorrhoea  in  the  female,  143 
mode  in  which  they  act,  114 
mode  of  giving,  123,  126,  143 
necessity  for  changing  questioned,  127 
time  at  which  they  may  be  safely  be- 
gun, 109 
various  opinions  as  to  the  strength  of, 

104 

Insufflation  as  a  remedy  in  gleet,  293 
Internal  remedies  in  gonorrhoea,  73 
Inveteracy,  connection  between  and  dia- 
thesis, 48 

Iodide  of  potassium.     (See  Potassium.) 
Iritis,  gonorrhoeal,  266 

gonorrhoeal,  pathology  of,  266 
gonorrhoeal,  prognosis  of,  267 
Irritants,  mechanical,  as  a  cause  of  gonor- 
rhoea in  the  male,  24 

JACKSON,  MR.  T.  CARR,  employment  of 

potassa  fusa  in  stricture  by,  285 
John  of  Gaddesden  describes  gonorrhoea,  5 
Johnson,  Mr.,  account  of  inflammation  of 
spongy   and   cavernous  bodies   by, 
206 
on  the  connection  between  inveteracy 

and  diathesis.  49 
on  the  genesis  of  gonorrhoea,  28 
on  the  results  of  antiphlogistic  treat- 
ment of  orchitis,  189 
on  the  value  of  sedatives  in  chordee, 

166 

Jones  and  Sieveking,  Messrs.,  on  pathol- 
ogy of  chordee,  163 
on  state  of  urethra  in  gonorrhoea,  35 
Jones.   Dr.  Bence,  on   alkalinity  of  urine 

after  meals,  155 

Jordon,  Mr.    Furneaux,  on   treatment  of 
gonorrhoeal  rheumatism  with  nitrate 
of  silver,  261 
on  treatment  of  orchitis  with  nitrate 

of  silver,  1 95 
Judd,  Mr.,  cases  of  orchitis  treated  with 

leeches  related  by,  189 
his  treatment  of  gonorrhoea.  65 
table  of  cases  treated  by,  118 
Jusseaume,  M.,  maintains  that  gonorrhoea 
is  due  to  a  vegetable  parasite,  45 

KAVA  KAVA  as  a  remedy  in  gonorrhoea,  81 

LABIA  MAJORA,  treatment  of  gonorrhoeal 
abscess  in,  149 

Laboulbene,  M.,  on  difference  between 
pathological  products  of  simple  and 
gonorrhoeal  rheumatism,  240 

Lacassagne,  M.,  case  of  gonorrhoeal  endo- 
carditis related  by,  248 

Lactic  acid  as  a  factor  in  acidity  of  urine, 
155 


INDEX. 


301 


Lacunas  of  urethra,  strong  tendency  to  in- 
flammation of,  213 

Laforgue,   M. ,    case   of  gonorrhoeal  peri- 
nephritic  abscess  related  by,  232 
Lagneau,  M.,  fils,  on  mode  of  formation  of 

peri-urethral  abscess,  215 
Lallemand's  caustic-holder,  objections  to, 

136 
Langlebert,  M. ,  his  treatment  of  orchitis, 

196,  197 
Lasegue,  M.,  account  of  gonorrhoeal  syno- 

vitis  by,  242 
on  atrophy  as  a  result  of  gonorrhoeal 

synovitis.  243 
Laudanum  in  scalding,  156 
Lawrence,  Sir  Win.,  case  of  failure  with 
antiphlogistic  treatment  in  gonor- 
rhoeal ophthalmia  related  by,  264 
on  arrest  of  gonorrhoeal  discharge  in 

gonorrhoeal  ophthalmia,  263 
on  excision  of  the  cornea  in  gonorrhceal 

opftthalmia,  266 

Lawson,  Mr.  George,  his  treatment  of  gon- 
orrhoeal ophthalmia,  263 
Ledeganck,  Herr,  on  seat  of  gonorrhoea  in 

the  male,  33 

Lee,  Mr.   Henry,  on  healthy  state  of  the 
female  organs  as  a  possible  cause  of 
gonorrhoea  in  male,  23 
the  origin  of  abscess  complicating  gon- 
orrhoea, 215 
recommends  strychnine    in   chordee, 

166 
Leeches,  doubtful  value  of,  in  gonorrhoea, 

89 

doubtful  value  of,  in  orchitis,  189 
Le  Fort,  M.,  on  period  of  incubation  of 

gonorrhoea,  37 
on  proportion  of  orchitis  to  gonorrhoea, 

186 
Leucorrhoea  as  a   cause  of   gonorrhoea  in 

the  male,  14 
degree   of  contagious   power   of,    14, 

21 
Linas,  M. ,  on  communication  of  gonorrhoea 

by  a  chaste  woman,  23 
Liquor  potassee  in  gonorrhoea,  94 
Lorey,  Dr. ,  account  of  treatment  of  gonor- 
rhoea with  gelatine  bougies  by,  121 
Lotions,  evaporating,  in  gonorrhoea,  95 

evaporating,  in  orchitis,  198 
Lloyd,  Mr.,  recommends  chloride  of  zinc 

as  an  injection  in  gonorrhoea,  113 
Lupulin  in  chordee,  166 

MACDONALD,  DR.  ANGUS,  on  Dr.  Noegge- 

rath's  views  about  gonorrhoea,  43 
Macnaraara,  Mr.,  punctures  the  testicle  in 

orchitis,  194 
Mallez,  M.,  mode  of  insufflation  in  gleet 

recommended  by,  292 
Marten,  John,  his  treatment  of  gonorrhoea, 

60 
Marty,  M. .  case  of  gonorrhoeal  endocarditis 

related  by,  248 


Marty,  M. ,  on  dangerous  nature  of  gon- 
orrhoeal endocarditis.  251 
Mason,  Dr.  Erskine,  objects   to   enemata 
and  suppositories  in  prostatic  inflamma- 
tion, 227 

Masturbation  as  a  cause  of  gonorrhoea,  24 
Matico  as  a  remedy  in  gonorrhoea,  83 
Mauriac,    M.,   on   forms  of  nervous  pain 

following  orchitis,  188 
on  origin  of  gonorrhoeal  rheumatism 

from  simple  urethritis,  239 
progressive    retention    of    urine    de- 
scribed by,  221 

Maymou,  M. ,  account  of  gonorrhoeal  syno- 
vitis by,  242 
on  the  influence  of  this  affection  on 

the  gonorrhoeal  discharge,  242 
on  restoration  to  normal  state  of  ten- 
dons affected  by  gonorrhoeal  syno- 
vitis, 244 
Medicine  as  a  branch  of  inductive  science, 

102 

Meningitis,  gonorrhceal,  251 
Menstrual  flow  as  a  source  of  gonorrhoea 

in  the  male,  22 

'  Menstruation,  excessive,  treatment  of,  149 
Mercury,   oleate  of,  in   perineal  abscess, 

226 
Mesue,  John,  evidence  of,  as  to  antiquity 

of  gonorrhoea,  3 
Metastasis,  in  gonorrhoeal  rheumatism,  255 

in  gonorrhoeal  orchitis,  170 
I  Meuriot,  M. ,  case  of  gonorrhoeal  (?)  endo- 
carditis related  by,  250 
Micrococcus  peculiar  to  gonorrhoea,  45 
Microscopic  products  of  gonorrhoea  in  the 
female,  identity  of,  with  those  of  leucor- 
rhoea,  19 
Miles,  Mr.  H.  Chalmers,  on  treatment  of 

acute  gonorrhoea  by  blistering,  137 
Monteggia,  early  mention  of  gonorrhoeal 

rheumatism  by,  235 
Morbid  sensibility  of  the  urethra,  215 
Morel,  M.  Emile,  cases  of  gonorrhceal  en- 
docarditis related  by,  249 
Morgan,  Dr.,  kind  of  syringe  recommended 

by,  129 
Morphia  in  orchitis,  198 

in  scalding,  156 

Morris,  Dr. .  his  mode  of  treating  gonor- 
rhoea, 104 

Moyle's  treatment  of  gonorrhoea,  59 
;  Murchison,  Dr. ,  fatal  cases  of  gonorrhceal 
( ?)  pyelitis  and  nephritis  communicated 
by. 232 
Musgrave,  William,  supposed  description 

ot  gonorrhceal  rheumatism  by,  234 
Myelitis,  gonorrhoeal,  252 

NEISSER,  DR.  ALBERT,  on  a  micrococcua 
peculiar  to  gonorrhoea,  46 

Nephritis,  gonorrbceal  (?),  253 

Ngan-plang  in  gonorrhoea,  82 

Niddrie,  Dr.,  mode  of  injecting  recom- 
mended by,  123 


302 


INDEX. 


Nitrate  of  silver.     (See  Silver,  nitrate  of.) 
Noeggerath,  Dr. ,  on  results  of  gonorrhoea, 

41 

on  treatment  of  gonorrhoea,  146 
Norman,  Mr.,  on  the  value  of  fresh  ground 

cubebs  in  gonorrhoea,  57,  80 
Nunn,  Mr.  Thomas,  on  difference  of  incu- 
bation  between    specific   and  non- 
specific discharges,  25 
on  non-existence  of  gonorrhceal  rheu- 
matism, 287 

successful  puncture  of  tunica  albuginea 
by,  193 

OIDTMANK,  DR.,  composition   for  use   in 

gonorrhoea  recommended  by,  121 
Ophthalmia,  gonorrhceal,  pathology  of,  262 
gonorrhosal,  prognosis  of,  263 
gonorrhceal,   proposed   treatment   of, 

265 
gonorrhoeal,     treatment    of,    usually 

adopted,  263 
Opium  as  a  remedy  in  chordee,  166 

as  a    remedy    in    gonorrhceal    rheu- 
matism, 259 

as  a  remedy  in  orchitis,  198 
Orcbitis,  causes  of,  173 

External  applications  in,  198 

origin  of,  from  extension  of  the  disease 

along  the  urethra,  170 
origin  of,  from  metastasis,  170 
origin  of,  from  sympathy,  170 
pathology  of,  170 
.     prognosis  of,  189 

proposed  treatment  of,  64 
results  of,  187 
statistics  of,  171 

treatment  of,  usually  adopted,  187 
Otis,  Dr.  Fessenden,  kind   of  syringe   re- 
commended by,  133 
on  employment  of  ball-staff,  283 
on  injecting    bladder   with    ordinary 

syringe,  130 

on  pathology  of  gleet,  271 
on  treatment  of  complications  of  gleet, 

288 

Ovaritis  from  gonorrhoea,  146 
acute,  cases  of,  146 
treatment  of,  146 

PAILT,ASSON,    M.,     recommendation     of 

starch  and  glycerine  in  gonorrhoea  by, 

121 

Pain  in  back,  treatment  of,  149 
Panas,  M.,  on  the   communication   of  the 

odor  of  sandal-wood  oil  to  the  urine,  85 
Paracelsus   arrays   gonorrhoea   among  the 

forms  of  syphilis,  10 
Paraphimosis,  treatment  of,  203 
Park.  Mr.    Robert,    on  sandal-wood  oil  in 

gonorrhoea,  85 
Pastilles  of  nitrate  of  silver  in  gonorrhoea, 

118 
Payne,  Mr.,  on  treatment  of  orchitis  with 

tincture  of  iodine,  198 


Penis,  inflammatory  swelling  of,  27 
Pericarditis,  gonorrhceal,  247 
Perineal  abscess,  224 
Perineum,  blistering  of.  in  gleet,  287 
Peri-nephritic  abscess,  gonorrhceal,  233 
Peritonitis,  gonorrhceal,  229 

gonorrhceal,  prognosis  of.  230 
gonorrhoeal,  treatment  of,  230 
Permanganate  of  potass.     (See  Potass.) 
Peter,  M.,  case  of  gonorrhoeal   peritonitis 

and  pleuritis  related  by,  230 
Phillips,  Mr.  Benjamin,  free  employment 

of  hot  baths  in  gonorrhoea  by,  9? 
on  the  termination  of  inflammation  of 

the  prostate  in  gangrene,  227 
on  the  treatment  of  urethral  fistulas, 

215 
Phillips,  M.   Charles,   on  results  of  gleet, 

293 

Phimosis.  treatment  of,  203 
Pidoux,  M. ,  on  difference  between  simple 

and  gonorrbceal  rheumatism,  240 
and  Guerin,  MM  .  on   existence  of  a 

gonorrhceal  lues.  40 
Piles  as  a  cause  of  gonorrhoea,  17 
Pills,  aperient,  in  gonorrhoea,  125 
Pitman,  Dr. .  case  of  death  from  abscess  of 

prostate  occurring  in  practice  of,  227 
Pleuritic,  gonorrhoeal  (?),  233 
Plug,  caustic,  134 
Point  at  which  infection  takes  place  in  the 

male,  32 

Potass,  acetate  of,  in  gonorrhoea,  94,  124 
chlorate  of.  in  gonorrhoea,  125 
nitrate  of,  in  scalding,  157 
permanganate  of,  as  an  injection,  101 
Potassa  fusa  in  stricture,  285 
Potassium,    bromide   of,    as  a  remedy  in 

chordee,  166 
iodide  of,  as  a  remedy  in  gonorrhoea, 

95 

iodide  of,  in  inflammation  of  the  pros- 
tate, 227 

iodide  of,  in  orchitis,  201 
Practitioner,    injection   of  cold   water    in 

gleet  recommended  in,  281 
Prettyman,  Dr.  J.  S.,  on  erigeron-oil  as  a 

remedy  in  gonorrhoea,  87 
Prostate,  abscess  of,  227 
inflammation  of,  226 
inflammation  of,  acute,  226 
inflammation  of,  divisions  of,  226 
inflammation  of,  mucous,  226 
inflammation  of,  pathology  of,  226 
inflammation  of.  prognosis  of,  227 
inflammation  of,  results  of,  227 
inflammation  of,  subacute,  226 
treatment  of  inflammation  of,  227 
Prostatic  gleet.     (See  Gleet.) 
Purdon.   Dr.  H.  S.,  on  sandal-wood  oil  in 

gonorrhoea,  85 

Pure  mucous  gleet.     (See  Gleet.) 
Purgatives  in  gonorrhoea,  89 

in  gonorrhoea,   great  use  of,  by  old 
surgeons,  90 


INDEX. 


303 


Purgatives,   table  of  cases  of  gonorrhoea 

treated  with,  90 
Pus-corpuscles   in  leucorrhoeal  secretion, 

significance  of,  19 
in  male  urethral  discharge,  significance 

of,  30 

Pyaemia,  gonorrhoeal,  253 
Pye-Smith,  Dr.,  case  of  gonorrhoeal  endo- 
carditis related  by,  250 
on  absence  of   eye  affection  in  com- 
mon rheumatism,  255 
occurrence  of  gonorrhoeal  rheumatism 
in  patients  previously  attacked  by 
rheumatic  fever,  237 
state  of  urine  in  gonorrhoeal  rheuma- 
tism, 240 

QUININE  in  gonorrhoeal  ophthalmia,  263 

in  gonorrhoeal  rheumatism,  258 
Quinquaud,  M.,  on  gonorrhoea  as  a  factor 

in  gonorrhoeal  rheumatism,  257 
feverishness  in   gouorrhoeal   rheuma- 
tism, 238 

RAGAZZONI  AND  APPIANI,  MESSRS.,  re- 
port by,  of  cases  of  orchitis  treated  with 
puncture  of  the  tunica  vaginnlis,  194 
Rectum,  excessive  irritability  of,  224 
Remedies,    variety   of,    recommended    in 

gonorrhoea,  54 

Remy.  M. ,  on  origin  of  ovaritis  from  gon- 
orrhoea, 54 
Rhazes,  mention  of  a  case  of  gonorrhoea 

by,  234 
Rheumatism,  gonorrhoeal,  brief  history  of, 

234 
gonorrhoeal,    cases  showing  extreme 

obstinacy  of,  245 

gonorrhoeal,  complications  of,  247 
gonorrhoeal,  divisions  of,  240 
gonorrhoeal,  in  women,  246 
gonorrhoeal,  mode  in  which  it  is  set 

up,  254 

gonorrhoeal,  pathology  of,  236 
gonorrhoeal,  prognosis  of,  257 
gonorrhoeal,    proposed   treatment  of, 

258 
gonorrhoeal,     treatment    of,    usually 

adopted,  257 

Richmond,    Mr.,    report  by,   of    cases    of 
orchitis  treated   with  puncture   of   the 
tunica  vagiualis,  194 
Ricord,  M.,  on  the  abortive  treatment  of 

gonorrhoea,  123 
on  the  development  of  gonorrhoea  by 

the  hot  bath,  54,  96 
on  the  genesis  of  gonorrhoea  in  the 

male,  19,  23,  24 

on  a  healthy  state  of  the  female  or- 
gans as  a  possible  cause  of  gonor- 
rhoea in  the  male,  23 
on  long  duration  of  gonorrhoea,  69 
on  specific  nature  of  discharge  from 
the  female  urethra,  27 


Ricord,  M.,  on  the  treatment  of  abscess  of 

the  vulva,  149 

on  the  treatment  of  chordee,  166 

on  table  of  cases  treated  by,  117 

Ricordi.  Dr.  Amilcar,  on  gleet  of  Cowper's 

ducts,  276 
on   treatment    of  gleet  of    Cowper's 

ducts,  292 
Robert,  M.  Melchior,    on  communication 

of  gonorrhoea  by  the  male,  31 
on  excision  of  conjunctiva  in  gonor- 
rhoeal ophthalmia,  266 
on  reappearance  of  spermatozoa  after 

orchitis,  188 

on   treatment  of   inflammatory  swell- 
ing of  penis,  205 
on  results  obtained  by,  in  treatment 

of  gonorrhoea,  89 
Roberts,  Dr.,  on  cause  of  acidity  of  urine, 

154 
Rocchi,  Dr. ,  on  importation  of  gonorrhoea 

into  country  districts,  19 
Rochoux,  M  ,  on  swelling  in  orchitis  being 
due  to  effusion  into  tunica  vaginalis,  173 
Rollet,  M.,  claims  to  have  discovered  con- 
nection of  gonorrhoeal  rheumatism 
with  rheumatism  of  eyeball,  267 
recognition   of  gonorrhoeal   synovitis 

by,  242 

Rowley  on  death  from  use  of  purgatives, 
89 

SALISBURY,  DR.,  on  origin  of  gonorrhoea 

from  a  fungus,  45 

Salleron,  M. ,  case  of  orchitis  treated  with 
bleeding  and  leeching  related  by, 
189 

on  limitation  of  inflammation  in  or- 
chitis to  epididymis,  172 
Salmon,  M. ,  case  of  gonorrhoeal  affection 
of  ducts  of  Duverney's  glands  related 
by,  148 

Sandal-wood  oil  in  gonorrhoea,  153 
Savory,    Mr.,  on   value  of   chloroform  in 

spasmodic  stricture,  222 
Scalding,  causes  of,  155 

effect  of  alkalies  upon,  158 
effect  of  anodynes  upon,  156 
effect  of  demulcents  upon,  157 
effect  of  diuretics  upon,  157 
pathology  of.  153 
probable  explanation  of,  161 
proposed  treatment  of,  161 
treatment  of,  usually  recommended, 

156 
Scarenzio,  Dr.  Angelo,  on  non-existence  of 

gonorrhoeal  rheumatism,  237 
Schuster,  Dr.,  on  glycero-tannin  rods  as  a 

remedy  in  gonorrhoea,  1 20 
on  sulphur  bath  in  subsequent  hard- 
ness  and    tenderness  of   prostate, 
228 

Sciatica,  gonorrhceal,  244 
Scrofula  as  a  cause  of  inveteracy,  49 
Scrotal  veins,  puncture  of,  in  orchitis,  190 


304 


INDEX. 


Scrotum,  blistering  of,  in  orchitis,  200 

puncture  of,  in  orchitis,  190 
Scythian  disease,  the,  described  by  Hero- 
dotus, 2 
Seat  of  gonorrhoea  in  the  female,  38 

in  the  male,  32 
Sedatives  in  the  treatment  of  orchitis,  196, 

198 
Seminal  vesicles,  inflammation  of.     (See 

Vesicles.) 

Sensibility,  morbid,  of  urethra,  134 
Severity  of  urethritis  not  evidence  of  its 

contagious  power,  27 

Sigmund,  Professor,  his  unfavorable  expe- 
rience of  soluble  bougies,  120 
Silver,   nitrate  of,   cauterization  with,  in 

acute  gonorrhoea  in  men,  110 
nitrate  of,  cauterization  with,  in  acute 

gonorrhoea  in  women,  143 
nitrate  of,  cauterization  with,  in  gleet, 

284,  292 

nitrate  of,  cauterization  with,  in  stric- 
ture, 218,  284 
nitrate    of,     cauterization     with,    in 

strong  tendency  to  stricture,  218 
nitrate  of,  injections  of,  110 
nitrate   of,    injections   of,    causes    of 

failure  with,  128 
nitrate  of,  pastilles,  118 
nitrate  of,  removal  of  stains  caused 

by,  126 

nitrate  of,  strong  injections  of,  111,  133 
nitrate  of,  table  of  cases  of  gonorrhoea 

treated  with,  111 
Simon,  Mr.  John,  on  treatment  of  irritable 

bladder,  169 
Simon,  of  Hamburg,  on  copaiba  eruption, 

79 

Simpson,  Sir  J.,  introduction  of  suppos- 
itories in  the  treatment  of  gonorrhoea  in 
the  female  by,  144 
Skin  diseases,  suppression  of,  as  a  cause 

of  gonorrhoea,  25 

Smith,  Dr.  W.  Tyler,  on  the  generation  of 
gonorrhoea  in  the  male  from  leucor- 
rhoea,  19 

on  the  identity  between  microscopic 
products  of  gonorrhoea  and  leucor- 
rhcea,  19 

on  the  secretion  of  lencorrhoea,  21 
Smith,  Mr.  Henry,  on  puncture  of  tunica 

albuginea  in  orchitis,  191 
Smith,  Mr.  Johnson,  on  puncture  of  unde- 

scended  testicle  for  orchitis.  193 
Smith,  Mr.  Noble,  on  necessity  for  vary- 
ing injections,  128 
Smoking  in  gonorrhoea,  151 
Specific  seat  of  gonorrhoea  in  male,  32 
Specifics  in  gonorrhoea  in  the  male.     (See 

Copaiba,  etc.) 

Spermatic  cord,  inflammation  of,  202 
Spongy  and  cavernous  bodies,  inflamma- 
tion of,  206 

Stains  caused   by  nitrate  of   silver  injec- 
tion, removal  of,  126 


Stein,  Professor,  on  erigeron-oil  in  gonor- 
rhoea, b'8 

Sterility  as  a  result  of  gonorrhoea,  41 
Stern,  Dr.  Adolf,  on  glycero-tannin  rods 

as  a  remedy  in  gonorrhoea,  120 
I  Stoll,  Dr..  on  after- death  appearances  in 

gonorrhoea,  35 

!  Strapping  the  testicle  in  orchitis,  195 
Stricture,  origin  of,  from  gonorrhoea,  70 
as  a  cause  of  persistency  of  gleet,  272 
strong  tendency  to,  216 
treatment  of,  216,  285 
Strychnia  as  a  remedy  in  chordee,  166 
Sub-peritoneal  inflammation  from  gonor- 
rhoea, 230 
prognosis  of,  231 
treatment  of,  231 

Suppositories,    employment  of,  in   gonor- 
rhoea in  the  female,  144 
inflammation  of  the  prostate,  227 
Suppuration  as  a  result  of  gonorrhceal  ar- 
thritis, 244 
Suspension  of  testicle  in  orchitis,  necessity 

for,  200 

Swediaur,  mention  of  gonorrhceal  rheuma- 
tism by,  235 

on  opium  as  a  remedy  in  orchitis,  197 
on  orchitis  being  due  to  extension  of 

gonorrhceal  inflammation,  171 
on  restriction  of  orchitic  inflaro  matioii 

to  epididymis,  172 
remarks  on  experiment  performed  by, 

28 

Swelling,  inflammatory,  of  the  peuis,  205 
Sydenham's  treatment  of  gonorrhoea,  58 
Synovitis,  gonorrhoeal,  pathology  of,  242 
proportion  of,  to  gonorrhceal  rheuma- 
tism, 242 
Syphilitic  gonorrhoea,  question  of  existence 

of,  95 

Syringe,  long  urethral,  132 
Syringes,  best  form  of,  128 
System,  infection  of,  by  gonorrhoea,  40 


TABLE  I.,  71;  II.,  75  ;  III,  90;  IV.,  91 ; 
V.,  Ill;  VI.,  115;  VII.,  117;  VIII., 
118  ;  IX.,  175 

Tachard,  M.,  his  treatment  of  orchitis,  195 
Talamon,    M. ,  cases  of  suppuration  from 

gonorrhoeal  arthritis  related  by,  245 
Tanner,  Dr.,  on  the  genesis  of  gonorrhoea, 

28 
on  infection  of  system  by  gonorrhoea, 

40 

on  ovaritis  from  gonorrhoea,  147 
on  the  specific  nature  of  gonorrhoea, 

18 

Tartar-emetic  in  treatment  of  orchitis,  189 
frictions   with,    in   treatment   of   or- 
chitis, 194 
Taylor,  Mr.  John,  on  acute  ovaritis  as  a 

complication  of  gonorrhoea,  147 
Taylor.  Dr.  R.  W.,  kind  of  syringe  recom- 
mended by,  133 


INDEX. 


305 


Taylor,   Mr.    Robert,  on  rarity  of  gonor- 

rhceal  iritis,  266 

Teevan,  Mr.,  on  connection  between  irri- 
table bladder  and  stricture,  169 
on  relaxing  power  of  ice  in  stricture, 

100 
on  value  of  ball-staff  in  diagnosis  of 

stricture,  282 

Thomas,  Dr.  Gaillarl,  on  employment  of 
suppositories  in  treatment  of  gonor- 
rhoea in  the  female,  144 
on  the  origin  of  gonorrhoea,  20 
Thompson,  Sir  Henry,  on  action  of  alka- 
lies upon  urine,  159 
on  soluble  bougies  in  gonorrhoea,  118 
on  triticum  repens  in  irritable  bladder, 

169 
Thorburn,  Dr. ,  on  Noeggerath's  theory  of 

gonorrhceal  infection,  44 
Thorn,  Mr.,  on  a  particular  preparation  of 

copaiba,  57,  78 
Tixier,  M ,  case  of  gonorrhceal  meningitis 

related  by,  251 
case  of  gonorrhceal  myelitis  related  by, 

252 
case  of  gonorrhoeal  adenitis  related  by, 

254 

case  of  gonorrhceal   (?)   hepatitis    re- 
lated by,  252 

case   of  gonorrhoeal   (?)   pleuritis  re- 
lated by,  234 
cases  of  gonorrhoeal  cardiac  affection 

related  by,  247 
on  the  form  of  discharge  which  pre-  , 

cedes  gonorrhoeal  rheumatism,  255 
on  the  non  suppression  of  discharge  in  j 
gonorrhoeal  affections  of  the  eye.  263  j 
Tomowitz.  M  ,  on  glycero- tannin  rods  as 

a  remedy  in  gonorrhoea,  120 
Tonics  in  gleet,  281 

in  gonorrhoea.  141.  150 
Trias  romaua,  gonorrhoea  mentioned  in,  8 
Triticum  repens  in  irritable  bladder,  169 
Tunica  albuginea,  puncture  of,  in  orchitis, 

191 

vasrinalis.  194 

Turner's  treatment  of  gonorrhoea,  61 
Turpentine  in  gonorrhoea,  82 
Tyrrell,  Mr.,  his  success  with  Thorn's  prep-  j 
aratiou  of  copaiba,  57,  78 

ULCERATION  of  mouth  and  neck  of  womb 

as  a  cause  of  gonorrhoea,  21 
Urethra,  cauterization  of,  for  gleet,  284 
cauterization    of,    for    gonorrhoea    in 

men,  136 
cauterization   of.    for    gonorrhoea    in 

women,  148 

morbid  sensibility  of.  2! 5 
post-mortem  state  of,  in  gonorrhoea,  35 
tender  state  of.  as  a  source  of  gonor- 
rhoea in  the  female,  28 
Urethral  gonorrhoea  in  the  female,  specific 

nature  of.  2('< 
treatment  of,  148 
•20 


Urethritis  from   leucorrhoea  or  vulvitis, 

non-specific  nature  of,  13 
from  mechanical  irritants  as  a  source 

of  gonorrhoea  in  the  female,  27,  32 
from  mechanical  irritants,  low  infec- 
tious power  of,  32 
milder  nature   of,   when   set  up   by 

mechanical  irritants.  24 
Uric  acid  as  a  cause  of  acidity  in  urine,  154 
Urine,  acidity  of,  153 

possibility   of    making    alkaline,   ex- 
amined, 158 
retention  of,  221 
retention  of,  treatment  of,  221 

VAGINA,  cauterization  of,  144 

Valescus   of    Tarentum   acquainted   with 

gonorrhoea,  6 

definition  of  gonorrhoea  by,  9 
Veale,  Dr. ,  on  mode  of  giving  copaiba,  77 
Yelpeau,  M. ,  on  frequent  inflammation  of 
seminal  vesicles  from  gonorrhoea,  228 
puncture  of  scrotum  in  orchitis  prac- 
tised by,  190 

Vesicles,  seminal,  inflammation  of,  228 
Vidal  de  Cassis,  puncture  of  tunica  albu- 
ginea practised  by,  191 
Villeneuve,   M.,  fatal  case  of  chordee  re- 
lated by, 165 
Virus   of  gonorrhoea,  specific  nature   of. 

(See  Pathology  of  Gonorrhoea.) 
Voelker,  M. .  cases  of  gonorrhoeal  cardiac 

affection  related  by,  247 
on   cold   as   a   determining   cause  of 

gonorrhoeal  rheumatism,  238 
on  climate  as  a  determining  cause  of 

gonorrhoeal  rheumatism,  238 
on    temperament    as    a    determining 
cause   of  gonorrhceal   rheumatism, 
238 

Vulvitis,  simple,  as  a  cause  of  gonorrhoea, 
13 

WAGNER  on  action  of  carbonate  of  soda 

on  urine,  159 
Wallace,  Mr.   W. ,  on  connection  between 

inveteracy  and  diathesis,  49 

on  the  pathology  of  chordee,  162 

Wasting  (see  Atrophy),  190,  193,  240,  243 

Water,   cold,   free  injection  with,   in  the 

treatment  of  gonorrhoea,  104 
hot,  as  an  application  in  chordee.  163 
hot,  as  an  application  in  gonorrhoea, 

98 
Waterman,  Dr. ,  his  treatment  of  orchitis, 

195 

Watson,  Mr.  Spencer,  cases  of  orchitis 
treated  by,  with  puncture  of  tunica 
vaginalis,  193,  194 

WTatson,  Sir  Thomas,  on  action  of  heat 
and  cold  as  outward  applications, 
100 

on  cause  of  acidity  of  urine,  154 
Weakness,  great  natural  or  induced,  209 
Weather  as  a  cause  of  orchitis.  209 


306 


INDEX. 


Weber,  Dr.  Hermann,  on  action  of  salycin 
and  its  congeners  in  gonorrhceal  rheu- 
matism, 258 
West,    Dr.,   on  treatment   of  gonorrhceal 

inflammation  of  uterus,  145 
Whately,  mention  of  gonorrhoea!  rheuma- 
tism by,  2o5 

on  purgatives  in  gonorrhoea,  90 
Windsor,  Mr  ,  mode  of  injecting  used  by, 

105 
Winternitz,  Herr,  experience  of,  with  cold 

water  injection  in  gleet,  281 
Womb,  purulent  discharge  from,  as  a  cause 

of  gonorrhoea,  21 
purulent  discharge  from,  treatment  of, 

145 
ulceration  of  mouth  and  neck  of,  as  a 

cause  of  gonorrhoea,  21 
Women,  genesis  of  gonorrhoea  in,  26 
gonorrhoeal  rheumatism  in,  246 


Women,  period  of  incubation  of  gonorrhoea 

in,  89 

seat  of  gonorrhoea  in.  38 
treatment  of  gonorrhoea  in,  142 

ZEISSL,  HERR,  case  of  sloughing  and  ex- 
pulsion of  mucous  membrane  of 
urethra  related  by,  112 

on  Langlebert's  treatment  of  orchitis, 
195,  J98 

on  the  necessity  for  changing  injec- 
tions, 128 

ou  want  of  curative  power  in  kava- 

kava.  82 

Zinc,  chloride  of,  as  an  injection  in  gonor- 
rhoea, 113 

injections  of.  as   a  possible  cause  of 
stricture,  113 

table   of   cases  of  gonorrhoea  treated 
with  injections  of,  115 


Date  Due 


PRINTED  IN  U.S.A.  CAT.    NO.   24    161 


000  522  409 


WC150 
M662  o 
188U 

Milton,  John  L. 

On  the  pathology  and  treatment 

of  gonorrhea 


WC150 
M662  o 
1881* 

Mi  It or ,  John  L. 

On  the  pathology  and  treatment  of 

gonori^ea 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


